neuro: anxiety

Question 1

OCD tx

Answer 1

1st line: SSRI
2nd: clomipramine
3rd: venlafaxine

Question 2

approach to dosing

Answer 2

􀂱 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)

Question 3

serotonergic antidepressant

Answer 3

• 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.

Question 4

bzd

Answer 4

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

Question 5

tolerance of bzd

Answer 5

• to hypnotic actions: common, develop within days
• to anxiolytic action: less common

Question 6

bzd dependence

Answer 6

avoid abrupt cessation after weeks of continued use (withdrawal)
- gradual taper required

Question 7

high potency bzd agents

Answer 7

usually preferred in aniety disorders
- clonazepam, lorazepam, alprazolam xr for panic disorder

Question 8

cautions to bzd

Answer 8

• parodoxical excitement esp in children and elderly
• dependence and withdrawal sx can occur esp in pt w hx of drug dependence

Question 9

tx not recommended

Answer 9

• kava: risk of hepatotoxicity
• chamomile: avoid in pregnancy
• valerien: incr gaba

Question 10

FDA-approved bzd for treatment of general anxiety

Answer 10

alprazolam, diazepam, lorazepam

Question 11

escitalopram dosing

Answer 11

10-20mg
PD, SAD: 5mg

Question 12

fluoxetine

Answer 12

Prozac

20mg starting dose, PD: 5mg

max 80mg

Question 13

fluvoxamine

Answer 13

Faverin

50mg, PD: 25mg
max 300mg

Question 14

paroxetine

Answer 14

Seroxat IR

20mg
40-60mg

Question 15

sertraline

Answer 15

Zoloft

5mg
200mg

Question 16

venlafaxine XR

Answer 16

Efexor XR

37.5-75mg
75-225mmf

Question 17

duloxetine

Answer 17

Cymbalta

30-60mg
max 60-120mg

Question 18

clomipramine

Answer 18

Anafranil

25mg
max 100-250mg

Question 19

mirtazapine

Answer 19

Remeron

15mg
max 30mg

Question 20

alprazolam

Answer 20

Xanax

0.5-4mg
max 4-10mg

Question 21

clonazepam

Answer 21

Rivotril

0.5-1mg
max 1-4mg

Question 22

diazepam

Answer 22

Valium

4-15mg
max 5-40mg

Question 23

lorazepam

Answer 23

Ativan

1-3mg
max 2-8mg

Question 24

hydroxyzine

Answer 24

Atarax

usually 25mg TDS-PRN
max 400mg

Question 25

proporanolol

Answer 25

10-80mg max 80-160mg

Question 26

pregabalin

Answer 26

Lyrica 150-600mg for GAD, if SSRI/SNRI ineffective or intolerable max 600mg

Question 27

which bzd not metabolised by cyp3a4?

Answer 27

lorazepam

Question 28

bzd + opioids

Answer 28

incr mortality, cns depression - avoid combi or limit dose and duraiton

Question 29

all serotonergic antidepressants

Answer 29

promote 5HT transmission

Question 30

ALL antidepressants that promote 5-HT transmissions have efficacy for anxiety disorders

Answer 30

effective for 'worrying/apprehension' type of sx - initiate at v low doses and gradually titrate up to max dose range

Question 31

time to respond to antidepressants

Answer 31

may take 6-12 weeks maximum response take 3 months

Question 32

discontinuation of antidepressants

Answer 32

gradual taper, to avoid discontinuation sx - decr dose by 10-25% every 1-2weeks

Question 33

early side effects to antidepressants use

Answer 33

possible incr anxiety during first 1-2 weeks - nausea, headache, insomnia/sedation usually subsides after 2-3 weeks of continued treatment

Question 34

long-term side effects to antidepressants use

Answer 34

sexual dysfunction and weight gain r common - may lead to discontinuation of treatment

Question 35

drugs that incr NE release

Answer 35

SNRI: venlafaxine, duloxetine NaSSA: mirtazapine NDRI: bupropion TCA will incr bp