Pharmacotherapy of Anxiety Disorders

Question 1

Drugs that can cause Anxiety

Answer 1

Albuterol

Caffeine (high dose)

Decongestants

Levothyroxine

Steroids

Stimulants (ADHD meds)

Question 2

Buspirone

Answer 2

Serotonin (5HT)-1a receptor agonist

Approved for GAD

Should be dosed with a target of 10 mg-15 mg TID

Make take up 3-4 weeks for initial efficacy

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 overuse death risk–specific warnings for co-prescribing with opioids

Question 4

Benzodiazepines (continued)

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 and may lead to increase fall risk

SE: sedation, paradoxical excitement, swallowing difficulties, impairment of memory and recall, and psychomotor impairment

D/C requires a slow taper over weeks to months

May be inappropriate in elderly

In elderly: prefer LOT (lorazepam, oxazepam, temazepam)

Question 5

Hydroxyzine

Answer 5

H1 antagonist and 5HT2a antagonist

Used to treat GAD

PRN

SE: prolong QT interval
sedation, dry mouth, constipation, blurred vision, confusion, urinary retention

Avoid use in > 65yo

Question 6

Gabapentin/pregabalin

Answer 6

anxiety + bipolar or neuropathic pain

Question 7

GAD

Answer 7

1. SSRI (Paroxetine and Escitalopram) or Buspirone

BZD are used as a bridge therapy for SSRI/SNRI onset

Hydroxyzine PRN

Question 8

Social anxiety disorder

Answer 8

at least 6 months

1. SSRI (paroxetine or sertraline)
   SNRI (venlafaxine) if fails

Beta blockers

Question 9

Panic disorder

Answer 9

symptoms: sweating, palpitations, dizziness, nausea, fear of losing control, going crazy

1. SSRI
   SNRI (Venlafaxine)
2. BZDs ( alprazolam or clonazepam)

Question 10

Obsessive-compulsive disorder (OCD)