neuro: anxiety Flashcards
OCD tx
1st line: SSRI
2nd: clomipramine
3rd: venlafaxine
approach to dosing
Starting Dose must be LOW: (start low go slow)
Transient jitteriness in the initial 1-2 weeks of starting antidepressant.
Start antidepressant at with low dose; consider Benzodiazepine as adjunct
Maintenance Dose may be at HIGH end of the range.
Effective maintenance dosing of antidepressants for treatment of Anxiety
Disorders are on the high end of the dose range (e.g. Fluoxetine 60-80mg/day vs 20mg for MDD)
serotonergic antidepressant
- effective for ‘excessive worrying’ type of symptoms in anxiety
Onset at least 1-2 months
Full response generally 3 months
Duration of treatment at least 1-2 years, typically long-term.
bzd
adjunctive: effective for physical sx of anxiety eg. muscle tension
- fast onset of action, can be within 30 mins for lorazepam
- aim for short term (3-4 months) of treatment, prn dosing, then taper
- anxiolytic, hypnotic, muscle relaxation, anticonvulsant, amnesic properties
tolerance of bzd
- to hypnotic actions: common, develop within days
- to anxiolytic action: less common
bzd dependence
avoid abrupt cessation after weeks of continued use (withdrawal)
- gradual taper required
high potency bzd agents
usually preferred in aniety disorders
- clonazepam, lorazepam, alprazolam xr for panic disorder
cautions to bzd
- parodoxical excitement esp in children and elderly
- dependence and withdrawal sx can occur esp in pt w hx of drug dependence
tx not recommended
- kava: risk of hepatotoxicity
- chamomile: avoid in pregnancy
- valerien: incr gaba
FDA-approved bzd for treatment of general anxiety
alprazolam, diazepam, lorazepam
escitalopram dosing
10-20mg
PD, SAD: 5mg
fluoxetine
Prozac
20mg starting dose, PD: 5mg
max 80mg
fluvoxamine
Faverin
50mg, PD: 25mg
max 300mg
paroxetine
Seroxat IR
20mg
40-60mg
sertraline
Zoloft
5mg
200mg
venlafaxine XR
Efexor XR
37.5-75mg
75-225mmf
duloxetine
Cymbalta
30-60mg
max 60-120mg
clomipramine
Anafranil
25mg
max 100-250mg
mirtazapine
Remeron
15mg
max 30mg
alprazolam
Xanax
0.5-4mg
max 4-10mg
clonazepam
Rivotril
0.5-1mg
max 1-4mg
diazepam
Valium
4-15mg
max 5-40mg
lorazepam
Ativan
1-3mg
max 2-8mg
hydroxyzine
Atarax
usually 25mg TDS-PRN
max 400mg
proporanolol
10-80mg
max 80-160mg
pregabalin
Lyrica
150-600mg for GAD, if SSRI/SNRI ineffective or intolerable
max 600mg
which bzd not metabolised by cyp3a4?
lorazepam
bzd + opioids
incr mortality, cns depression
- avoid combi or limit dose and duraiton
all serotonergic antidepressants
promote 5HT transmission
ALL antidepressants that promote 5-HT transmissions have efficacy for
anxiety disorders
effective for ‘worrying/apprehension’ type of sx
- initiate at v low doses and gradually titrate up to max dose range
time to respond to antidepressants
may take 6-12 weeks
maximum response take 3 months
discontinuation of antidepressants
gradual taper, to avoid discontinuation sx
- decr dose by 10-25% every 1-2weeks
early side effects to antidepressants use
possible incr anxiety during first 1-2 weeks
- nausea, headache, insomnia/sedation usually subsides after 2-3 weeks of continued treatment
long-term side effects to antidepressants use
sexual dysfunction and weight gain r common
- may lead to discontinuation of treatment
drugs that incr NE release
SNRI: venlafaxine, duloxetine
NaSSA: mirtazapine
NDRI: bupropion
TCA
will incr bp
