S54 - Pharmacology of Anxiety Disorders

Question 1

_____________ are the most effective and safe (relatively) for rapid relief of anxiety symptoms.

Answer 1

Benzodiazepines

BZD's
clobazam (Onfi®)
clonazepam (Klonopin®)
clorazepate (Tranxene®)
diazepam (Valium®)
lorazepam (Ativan®)

Question 2

_________ is an optional treatment in patients without comorbid depression or other anxiety disorders.

Answer 2

Buspirone (Buspar)

Question 3

First Line therapy for Generalized Anxiethy Disorder (GAD)

Answer 3

Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafexine XR (Effexor)

Question 4

First Line therapy for Panic Disorder

Answer 4

SSRI’s

• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• citalopram (Celexa)
• escitalopram (Lexapro)
• vortioxetine (Trintellix)

Venlafexine XR (Effexor)

Question 5

First Line Therapy for Social Anxiety Disorder

Answer 5

Escitalopram (Lexapro)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafexine XR (Effexor)
Fluvoxemine CR

Question 6

Aytpical antipsychotics low-dose have been used for GAD –

Answer 6

Quetiapine 150 mg = paroxetine 20 mg/day.

Question 7

Pregabalin is used in Europe as a first-line agent for GAD.

Answer 7

Off-label at best in the USA.

Not included into treatment algorithms.

Question 8

Antidepressants are considered the first-line agents in GAD.

Answer 8

Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafexine XR (Effexor)

Question 9

FDA approved for Generalized Anxiety Disorder (GAD)

Response is delayed 2-4 weeks.

Answer 9

paroxetine (Paxil)
duloxetine (Cymbalta)
venlafaxine (Effexor)
escitalopram (Lexapro)

Question 10

________ is FDA approved for PD with or without agoraphobia.

Answer 10

Alprazolam (Xanax)

Question 11

FDA Approved agents for acute anxiety

Answer 11

Alprazolam (Xanax)
clonazepam (Klonopin®)
clorazepate (Tranxene®)
diazepam (Valium®)
lorazepam (Ativan®)
chlordiazepoxide (Librium)
Oxazepam (Serax)

Question 12

IM administration of diazepam and chlordiazepoxide should be AVOIDED –

Answer 12

erratic absorption and painful.

Question 13

Which BZD’s are glucuronidated?

Answer 13

Only lorazepam and oxazepam are glucuronidated

Question 14

Clonazepam undergoes

Answer 14

nitroreduction.

Question 15

Diazepam is also metabolized by

Answer 15

CYP 2C19

Question 16

__________ is a prodrug converted to DMDZ in the GI tract under acidic pH. Watch out for antacid use!

Answer 16

Clorazepate

Long-acting BZ are metabolized to desmethyldiazepam (DMDZ) – active metabolite.

Question 17

BZ efficacy – 65-75% response rate within 2 weeks.

Only effective for the

Answer 17

somatic symptoms.

Question 18

Unique to benzodiazepines where patient can become highly agitated and increased BZD’s increases agitation.

Answer 18

Disinhibition syndrome

Question 19

_________ _________ – rebound anxiety with Increased symptoms greater than baseline.

Answer 19

Benzodiazepine discontinuation

Question 20

BZD’s have drug interactions with:

Answer 20

CYP3A4 inhibitors (ketoconazole) and inducers (carbamazepine).

Question 21

__________ – nonBZ without anticonvulsant, hypnotic, motor impairment or dependence .

Answer 21

Buspirone (Buspar)

2nd line agent for GAD.
Delayed onset > 2 weeks.

MOA: 5-HT1A partial agonist activity at presymaptic neurons ↓ firing of 5-HT neurons.

Do not use with MAOI’s for concern of serotonin syndrome.

Question 22

Pregnancy avoids

Answer 22

Antidepressants (SSRI’s and TCA’s) are preferred agents for pregnant pts. except paroxetine.

Benzodiazepines (BZs) associated with cleft lip and cleft palate in babies.

Clinicians avoid BZs during the 1st trimester.

BZs use in the 3rd trimester: sedation, withdrawal and “floppy baby syndrome.”

Alprazolam and lorazepam reported to cause neonatal withdrawal symptoms.

Question 23

Panic Disorder (PND)

Answer 23

SSRI’s are considered first-line due to safety and tolerability.

Combination of psychotherapy and drug therapy.

CBT is used 16-20 hrs over 4 months

Question 24

Panic Disorder (PND) treatment duration

Answer 24

Acute phase TX. : 1-3 months, therapy altered if no response found 6-8 weeks.
Maintenance Tx. : 12-24 months, drug dc’d over 4-6 months.
Monitor for various issues – BZ dependence, SSRI withdrawal syndrome and etc

Question 25

FDA Approved for Generalized Anxiety Disorder

Answer 25

``` Sertraline (Zoloft) Paroxetine (Paxil) Escitalopram (Lexapro) Venlafaxine (Effexor) Duloxetine (Cymbalta) Buspirone (Buspar) ```

Question 26

FDA Approved for Social Anxiety Disorder

Answer 26

Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine Venlafaxine (Effexor)

Question 27

FDA Approved for Panic Disorder

Answer 27

Sertraline (Zoloft) Paroxetine (Paxil) Clonazepam (Klonopin) Alprazolam (Xanax)

Question 28

Special populations: SAD present in young children.

Answer 28

Monitored closely for suicidal ideation when SSRI or SNRI is used. BZs’ last line of agents for children with SAD. 1/5 pts. also have alcohol use. Do not use MOAI’s. Careful use of BZs.

Question 29

SNRI’s: effective for pts. Who do not respond to SSRI’s. | Use like for depressed pts.

Answer 29

Mirtazapine 30 mg/day was used in women over 10 weeks. BZ’s: reserve use for pts. who can not use SNRI’s or SSRI’s. Gabapentin was reported to be effective. beta-blockers were found not be effective for daily use.

Question 30

__________ were developed for treatment of anxiety disorders, but are 2nd line agents after SSRIs/SNRIs

Answer 30

Benzodiazepines

Question 31

Are the benzodiazepines considered the “first-line” agent for GAD treatment?

Answer 31

NO… SSRIs/SNRIs

Question 32

Can benzodiazepines be abruptly discontinued?

Answer 32

NO… withdrawal symptoms can occur

Question 33

What is the minimum amount of time needed for treatment with a SSRI for patient with PND who responses to a SSRI agent?

Answer 33

Minimum 12 mons/ can be up to 24 mos.

Question 34

BZ’s: alprazolam is the ideal agent who need rapid relief (1-2 weeks). Relapse rates 50% or higher.

Answer 34

True

Question 35

SNRI’s was reported to be effective 54-60% respond.

Answer 35

True

Question 36

SAD: When drug were dc’d after 2-3 months, relapse > than 5-12 months.

Answer 36

True

Question 37

SSRI’s and SNRI’s are equally effective. | TCA’s are not effective in SAD.

Answer 37

True

Question 38

``` SAD Start with: - fluoxetine (Prozac) - sertraline (Zoloft) - paroxetine (Paxil) - citalopram (Celexa) - escitalopram (Lexapro) - vortioxetine (Trintellix) or venlafexine for 12 weeks ```

Answer 38

True

Question 39

``` SAD Start with: - fluoxetine (Prozac) - sertraline (Zoloft) - paroxetine (Paxil) - citalopram (Celexa) - escitalopram (Lexapro) - vortioxetine (Trintellix) or venlafexine for 12 weeks ``` IF RESPONSE

Answer 39

Continue for 12 weeks

Question 40

``` SAD Start with: - fluoxetine (Prozac) - sertraline (Zoloft) - paroxetine (Paxil) - citalopram (Celexa) - escitalopram (Lexapro) - vortioxetine (Trintellix) or venlafexine for 12 weeks ``` IF NO RESPONSE

Answer 40

SWITCH SSRI or if not used venlafexine use that

Question 41

``` SAD Start with: - fluoxetine (Prozac) - sertraline (Zoloft) - paroxetine (Paxil) - citalopram (Celexa) - escitalopram (Lexapro) - vortioxetine (Trintellix) or venlafexine for 12 weeks ``` if PARTIAL response

Answer 41

Augment with Buspar or clonazepam

Question 42

SNRI’s: effective for pts. Who do not respond to SSRI’s

Answer 42

True

Question 43

Mirtazapine 30 mg/day was used in women over 10 weeks.

Answer 43

True