Ott Pharmacotherapy of Anxiety Flashcards by Corey Brend

Drugs that can cause anxiety

-Albuterol
-Caffeine (high dose 800mg)
-Decongestants
-Levothyroxine
-Steroids
-Stimulants (ADHD meds)

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What are the medications used to treat anxiety disorders?

-Buspirone
-BZDs
-SSRIs
-SNRIs
-Hydroxyzine
-Herbal supplements

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Buspirone mechanism of action

Serotonin (5HT)-1a receptor agonist

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Buspirone approved indicated use

Generalized anxiety disorder

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How long does it take buspirone to take effect?

3-4 weeks for initial effectiveness

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Buspirone dosing

Should be dosed with a target of 10 mg - 15 mg three times daily (30 mg - 40 mg total/day)

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BZD clinical pearls

-Many treatment guidelines do not support the use of BZDs in routine practice due to misuse potential, but the effect size for efficacy in anxiety disorders is higher than serotonergic antidepressants in some studies
-Long-term use is not recommended due to risk of dependence and tolerance
-Acute withdrawal of BZDs may lead to seizures that can be life-threatening (requires slow taper over weeks to months)
-Warnings for the use of BZDs with other CNS depressants and overdose death risk - specific warnings for co-prescribing with opioids
-May be inappropriate in the elderly

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Which BZDs do not have an active metabolite?

-Alprazolam
-Lorazepam
-Clonazepam
-Oxazepam
-Less likely to accumulate but still have a fall risk

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Which BZDs have a long-acting active metabolite?

-Diazepam
-Clorazepate
-Chloriazepoxide

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BZD side effects

-Sedation
-Paradoxical excitement
-Swallowing difficulties
-Impairment of memory and recall
-Psychomotor impairment

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When is hydroxyzine used?

-Hydroxyzine pamoate is FDA-approved for the treatment of generalized anxiety disorder (can also use HCl salt for lower 10 mg dose)
-“as needed” for anxiety or insomnia instead of a BZD

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Hydroxyzine side effects

-Sedation
-Anticholinergic side effects
-QTc prolongation risk
-Avoid use in the elderly due to anticholinergic side effects and fall risk

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What is propranolol used to treat?

-Decrease physiological symptoms of acute anxiety (tachycardia, sweating, flushing)
-Useful for performance and situational anxiety

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How to dose propranolol

Low doses - 10 mg - 20 mg - three times daily or LA dosage form

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Propranolol monitoring

Evaluate for history/current asthma and cardiovascular conditions

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Natural products used for anxiety

-Kava
-St. Johns wort
-Passionflower
-Valerian
-Chamomile

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Kava side effects

-Hepatotoxicity
-May cause platelet aggregation
-May aggravate symptoms of Parkinsons disease

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St. Johns wort clinical pearls

-Likely a mild MAO inhibitor
-Can increase the chance of serotonin syndrome
-Commonly used for anxiety and depression
-Strong 3A4 inducer
-Watch for drug interactions

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Valerian clinical pearls

-May have properties similar to BZDs
-Avoid use in pregnancy
-Reports of hepatotoxicity

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Passionflower clinical pearls

-May cause dizziness, ataxia, confusion
-Avoid use in pregnancy due to uterine stimulation and induction of early labor

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Chamomile clinical pearls

-Avoid with blood thinners and ragweed allergy

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Lavender clinical pearls

-Decrease blood pressure
-Constipation
-Headache
-Increased appetite

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Lemon balm clinical pearls

GI upset

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When can gabapentinoids be used?

May be considered in patients with bipolar disorder who has anxiety symptoms or comorbid neuropathic pain

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Use of quetiapine in anxiety

-The active metabolite is theorized to have anxiolytic properties -Evidence base is limited for anxiety and sleep medicine does not endorse the use of quetiapine for insomnia

What is first-line therapy for all anxiety disorders?

-SSRIs and SNRIs -Buspirone can also be used first-line for generalized anxiety disorder

Where is BZDs place in anxiety treatment?

-They are FDA-approved to treat anxiety disorders -Treatment guidelines suggest only using them if necessary

When to use atypical antipsychotics

-Not FDA-approved -Clinical evidence suggests efficacy for treatment-resistant OCD (aripiprazole and risperidone)

Definition of generalized anxiety disorder

Excessive anxiety/worry present for at least 6 months

Symptoms of generalized anxiety disorder

-Restlessness/feeling keyed up or on edge -Being easily fatigued -Difficulty concentrating or mind going blank -Irritability -Muscle tension -Sleep disturbances

First-line treatment for generalized anxiety disorder

-SSRIs -SNRIs -Buspirone -All drugs are equally as effective so pick best drug for patient

How long does it take to see initial onset of symptom relief for SSRIs?

2-4 weeks

When are SNRIs useful as first-line?

If patient also has a pain syndrome

When are BZDs used in generalized anxiety disorder?

-"Bridge therapy" to cover time until onset of SSRI/SNRI, where appropriate -MUST taper if the patient has been taking long-term treatment to avoid withdrawal

When can hydroxyzine be used for the treatment of GAD?

As needed

What are the medications that are used to treat GAD?

-SSRI antidepressants -SNRI antidepressants -BZDs -Buspirone -Hydroxyzine

What is social anxiety disorder?

-Persistent fear about social and/or performance situations in which the patient fears embarrassment or humiliation that is unreasonable -Specific situations may be avoided in a manner that interferes with a patient's normal routine -Duration of symptoms is at least 6 months

Which medications are used for the treatment of social anxiety disorder?

-SSRIs -SNRIs -Beta-blockers

What is first-line treatment for SAD?

SSRIs (paroxetine and sertraline are FDA-approved)

When are SNRIs recommended for patients with SAD?

Useful when SSRIs fail (Venlafaxine is FDA approved)

When are beta-blockers used in SAD?

Non-generalized, performance-related SAD

Definition of panic disorder

-Recurrent, unexpected panic attacks -Abrupt surge of intense fear or discomfort -At least 4 physical and psychological symptoms, including sweating, palpitations, nausea, dizziness, fear of losing control, "going crazy", or dying -At least one attack has been followed by one month or more of at least one of the following: persistent concern about additional attacks, significant maladaptive change in behavior related to the attacks

Which medications are recommended for the treatment of panic disorders?

-SSRIs -SNRIs (venlafaxine is FDA approved) -BZDs

Which medication is first-line treatment for panic disorder?

SSRIs

When are BZDs used for treatment of panic disorder?

BZDs should not be considered first-line maintenance therapy unless there is inadequate response to serotonergic drugs

Definition of obsessive-compulsive disorder

-Obsessions: recurrent thoughts or images that are intrusive or cause anxiety; patients attempt to ignore, suppress, or neutralize with other thoughts or actions -Compulsions: repetitive behaviors or mental acts performed in response to obsession; aimed at reducing or preventing distress; not always connected in a realistic way to the fear

Drugs used to treat OCD

-SSRIs -Clomipramine (TCA) -Antipsychotics

What is considered first-line treatment of OCD?

SSRIs

What is considered second-line treatment for OCD?

Clomipramine

When would antipsychotics be used for treatment of OCD?

Considered as augmentation therapy with SSRIs/SNRIs

Which antipsychotics have the best data for use with OCD?

-Risperidone -Aripiprazole

How much can SSRIs reduce symptoms of OCD?

25-50%

Definition of posttraumatic stress disorder

Exposure to real or threatened death, serious injury, or sexual violence (either victim, witness, discovery, exposure to details of traumatic event)

Symptoms of PTSD

-Flashbacks -Reexperiencing -Avoidance of stimuli associated with the event -Hypervigilance (exaggerated startle response) -Negative alterations in mood or cognition

How to treat PTSD

-SSRIs/SNRIs -Prazosin -Polytherapy -CBT/eye movement desensitization/reprocessing

What is first-line treatment for PTSD?

SSRIs/SNRIs (only class of drugs FDA approved for PTSD)

What can be used to help induce sleep/get rid of nightmares in patients with PTSD?

Prazosin

Which class of medications is NOT recommended in the treatment of PTSD?

BZDs

What is a common comorbidity of PTSD?

Substance use

Issues associated with SSRI/SNRI use

-Jitteriness syndrome (initial doses should be lower than that used for depression to prevent this) -Onset of action is 2-4 weeks

Issues associated with BZDs

-Evaluate severity of anxiety disorder impact on functionality before considering using bridge therapy -Abrupt dc can be life-threatening

Non-pharmacologic treatment of anxiety disorders

-Psychotherapy and CBT -In PTSD - drug therapy is more effective in civilian trauma vs combat trauma, so non-drug treatments are especially useful