pharmacotherapy of Anxiety

Question 1

Drugs that cause Anxiety

Answer 1

Albuterol, Caffeine (high dose), Decongestants,Levothyroxine, Steroids, Stimulants (ADHD meds)

Question 2

Buspirone

Answer 2

Buspirone is a serotonin (5HT)-1a receptor agonist
use in generalized anxiety disorder
Should be dosed with a target of 10 mg – 15 mg three times daily (30 mg – 45 mg total/day)
May take up to 3 - 4 weeks for initial efficacy - patients should be counseled

Question 3

Benzodiazepines

Answer 3

Many treatment guidelines do not support the use of benzodiazepines 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
Acute withdrawal of benzodiazepines may lead to seizures
that can be life-threatening
Warnings for the use of benzodiazepines with other CNS
depressants and overdose death risk – specific warnings for
co-prescribing with opioids

Question 4

Benzodiazepines drugs

Answer 4

Alprazolam, lorazepam, clonazepam, and oxazepam do not have an active metabolite and are less likely to accumulate, while they have a fall risk
Diazepam, clorazepate, and chlordiazepoxide have a long-acting active metabolite

Question 5

Benzodiazepine clinical pearls

Answer 5

Side effects include sedation, paradoxical excitement, swallowing difficulties, impairment of memory and recall, and psychomotor impairment
Discontinuation of benzodiazepines requires a slow
taper over weeks to months
Beer’s Criteria: may be inappropriate in the elderly elderly – prefer L-O-T (lorazepam, oxazepam, temazepam)

Question 6

Propranolol

Answer 6

Decrease physiological symptoms of acute anxiety
Useful for performance and situational anxiety in as needed doses
Low doses
Evaluate for history/current asthma and cardiovascular conditions

Question 6

Hydroxyzine

Answer 6

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 benzodiazepine
Sedation and anticholinergic side effects are prominent, QTc prolongation risk
Avoid use in the elderly due to anticholinergic side effects and fall risk

Question 7

Kava

Answer 7

natural product may cause hepatotoxicity/liver failure use is not recommended;

Question 8

st John’s Wort

Answer 8

strong 3A4 inducer, watch for drug interactions,: mild MAO inhibitor – do not
take with other antidepressants or serotonergic drugs – serotonin syndrome
risk

Question 9

Passionflower

Answer 9

natural product avoid in pregnancy due to a risk of uterine stimulation

Question 10

Valerian

Answer 10

natural product void use of valerian in pregnancy;

Question 11

Chamomile

Answer 11

natural product, (avoid with blood thinners and ragweed allergy)

Question 12

Quetiapine

Answer 12

theorized to have anxiolytic properties; quetiapine is sometimes prescribed both for anxiety and sleep; the evidence base is limited for anxiety and sleep medicine does not endorse the use of quetiapine for insomnia

Question 12

Gabapentinoids

Answer 12

Gabapentinoids may be considered in a patient with bipolar disorder who has anxiety symptoms or comorbid neuropathic pain

Question 13

Drug therapy principles for anxiety disorders

Answer 13

SSRIs and SNRIs are first-line therapy for all anxiety disorders
Buspirone can also be used first-line for generalized anxiety disorder
Benzodiazepines are FDA-approved to treat anxiety disorders, but treatment guidelines suggest using them only if necessary
Atypical antipsychotics are not FDA-approved for anxiety disorders, but clinical evidence suggests efficacy for treatment-resistant OCD (aripiprazole
and risperidone)

Question 14

DSM-5, TR Generalized Anxiety Disorder

Answer 14

Excessive anxiety/worry, present for at least 6 months
Restlessness/feeling keyed up or on edge, Being easily fatigued
Difficulty concentrating or mind “going blank” Irritability Muscle tension
Sleep disturbances

Question 15

Treatment of GAD

Answer 15

first-line maintenance treatment are the SSRI antidepressants: Take 2 – 4 weeks
SNRI antidepressants:Useful first-line if patient also has a pain syndrome
BenzodiazepinesLBridge 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
Buspirone
Hydroxyzine as needed QTc prolongation risk

Question 16

DSM-5, TR Social Anxiety Disorder

Answer 16

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 the patient’s normal routine
Duration of symptoms is at least 6 months

Question 17

treatment of social anxiety disorder

Answer 17

SSRIs are first-line treatment,SNRIs – may be useful if failure of SSRI,Beta-blockers may be useful for non-generalized, performance-related SAD

Question 18

DSM-5 Panic Disorder

Answer 18

Recurrent, unexpected panic attacks, abrupt surge of intense fear or discomfort
and is accompanied by 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

Question 18

Treatment of Panic Disorder

Answer 18

SSRIs are first-line maintenance treatment, SNRIs – Venlafaxine is FDA-
approved,Benzodiazepines should not be considered first-line
maintenance therapy unless there is inadequate response to serotonergic drugs

Question 19

DSM-5, TR Obsessive- Compulsive Disorder

Answer 19

Obsessions:Recurrent thoughts or images that are intrusive and cause anxiety; patient attempts 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

Question 20

Tx of OCD

Answer 20

The SSRIs are first-line treatment for OCD.
A 25 – 50% reduction in symptoms can be expected.
If the patient fails a few trials of different SSRIs, clomipramine (TCA) is considered second-line treatment
Antipsychotics are not FDA-approved for OCD, may be considered as augmentation therapy with SSRIs/SNRIs
Risperidone has the best clinical data for effectiveness
aripiprazole, inconsistent efficacy

Question 21

DSM-5, TR Posttraumatic Stress Disorder

Answer 21

Exposure to real or threatened death, serious injury, or sexual violence (either victim, witness, discovery, exposure to details of traumatic event.(flashbacks),(reexperiencing), avoidance, hypervigilance,Negative alterations in mood or cognition

Question 22

treatment of PTSD

Answer 22

SSRIs/SNRIs are first-line treatment, only class of drugs FDA-approved for PTSD Prazosin may be helpful for sleep or nightmares Benzodiazepines are NOT recommended in PTSD Polytherapy is common in PTSD Substance use is common Cognitive behavioral therapy and eye movement desensitization and reprocessing

Question 23

Selected Drug Therapy Issues in Anxiety Disorders

Answer 23

“Jitteriness” syndrome can result from the use of the SSRIs and SNRIs when treating anxiety disorders Initial doses should be lower than doses used for depression to minimize the “jitteriness” side effect Onset of action 2-4 weeks SSRI/SNRI Evaluate the severity of impact on functionality by the anxiety disorder before considering using “bridge therapy” with benzodiazepines Abrupt d/c of benzodiazepines can be life-threatening

Question 24

Non-pharm tx

Answer 24

Psychotherapy and cognitive behavioral therapy in PTSD – drug therapy may be more effective in civilian trauma (usually a one-time event) versus combat trauma (traumatic events occurring over a longer period of time), so non-drug treatments are especially useful