-
Goals of therapy for GAD
Manage acute sx-by reducing frequency, duration and severity of anxiety and improve overall fxn.
Long term - remission with minimal or no anxiety sx, no fxnal impairment and increased QOL
-
First line drugs for GAD
- Duloxetine
- Escitalopram
- Paroxetine
- Venlafaxine XR
-
Second line drugs for GAD
- BZDs
- Buspirone
- Imipramine
- Sertraline
-
-
First line drugs for Panic Disorder
-
Second line drugs for Panic disorder
- Alprazolam
- Clomipramine
- Clonazepam
- Imipramine
-
Alternative drug(s) for panic disorder
Phenelzine
-
First line durgs for social anxiety disorder
- Escitalopram
- Fluvoxamine
- Paroxetine
- Sertraline
- Venlafaxine XR
-
Second line drugs for Social Anxiety Disorder
-
Alternative drugs for social anxiety disorder
- Buspirone
- Gabapentin
- Mirtazapine
- Phenelzine
- Pregabalin
-
DOC for acute management of anxiety symptoms
BZDs
-
Alprazolam dosage range for anxiety disorders
0.75-4mg/day
-
Chlordiazepoxide dosage range for anxiety disorders
25-100mg/day
-
Clonazepam dosage range for anxiety disorders
1-4mg/day
-
Clorazepate dosage range for anxiety disorders
7.5-60mg/day
-
Diazepam dosage range for anxiety disorders
2-40mg/day
-
lorazepam dosage range for anxiety disorders
0.5-10mg/day
-
oxazepam dosage range for anxiety disorders
30-120mg/day
-
Duloxetine dosage range for GAD
60-120mg/day
-
Escitalopram dosage range for GAD
10-20mg/day
-
Imipramine dosage range for GAD
75-200mg/day
-
Paroxetine dosage range for GAD
20-50mg/day
-
Venlafaxine dosage range for GAD
75-225mg/day
-
Buspirone dosage range for GAD
15-60mg/day
-
Hydroxyzine dosage range for GAD
200-400mg/day
-
Pregabalin dosage range for GAD
150-600mg/day
-
At dosages less than 225mg/day this drug functions more like an SSRI
Venlafaxine
-
MOA of venlafaxine
Potent inhibitor of 5HT and NE reuptake (SNRI) and a moderate effect of DA uptake
-
Common side effects of venlafaxine
- nausea(37%)
- vomiting(6%)
- insomnia
- dry mouth
- somnolence
ADRs are a fxn of dose
Increases SDBP is higher at >300mg/day and this dose is not recommended
-
Second line option for GAD and alternate option for pts with substance abuse history
May be more effective in treating psychic sx rather than somatic
Buspirone
-
MOA of buspirone
Inhibit 5hT1A and 5HT2 receptors
-
Side effects of buspirone
- Fewer than BZDs
- Dizziness (12%)
- Drowsiness (10%)
- Nervousness (9%)
- Uneasiness
- HA
- --common at doses > 20mg/day
- ETOH and buspirone in combo does not impair performance
-
Fear of being in a place or situation where fleeing or obtaining help might be difficult. Patients befin to avoid these places or experience severe anxiety
Agoraphobia
-
Risk factors for Panic Disorder
- Genetic component - First degree relative dx will have greater likelihood and twins
- Women 2x greater than men
- Rate of recurrence after remission is higher in women
- Agoraphobia can occur at anytime but often develops within first year
-
Intrusive and recurrent thoughts
Obsession
-
Ritualistic behavior
Compulsions
-
CBT is as effective as pharmacotherapy for this disorder
panic disorder
-
First line therapy for OCD
- SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline FDA approved)
- Clomipramine
-
Scales for OCD
Y-BOCS (Yale-Brwwon Obsessive Compulsive Scale)
-
Essential characteristics of GAD
- Persistent excessive worry accompanied by symtoms suggestive of CNS arousal (irritability, muscle tension, insomnia, restlessness, sweating)
- Intensity, duration or frequency of worry exceeds what is warrented by the event
- Theme or types of worry may change over time
-
GAD Rating Scales
- HAM-A - Hamilton Rating Scale for Anxiety
- SAS - Zung Self-rating anxiety scale
- State-Trait Anxiety inventory - patient rated
-
Only TCA efficacious for OCD
Clomipramine
-
Adverse effects of clomipramine
- Anticholinergic
- Cardiovascular
- Weight gain is common
- Increased seizure risk (doses >250mg/day)
-
Alternative pharmacotherapy for nonresponders in OCD
Venlafaxine
-
These drugs may increase clomipramine levels and may be used to augment therapy
- Fluvoxamine
- Paroxetine
- Fluoxetine
- --May increase clomipramine levels
- Pts >40 should receive EKG
- Monitor BP and Pulse
-
Types of PTSD
- Acute (<3months)
- Chronic (>3months)
- Delayed onset (>6 months between onset of sx and traumatic event)
-
Name the three clusters of PTSD sx
- Re-experiencing
- Avoidance
- Increased arousal
- --Pt should have sx from each
-
Pharmacotherapy as monotherapy is usually not beneficial for this disorder
PTSD - up to 70% of pts have response to pharm and nonpharmacologic therapy
-
Adults with mild acute PTSD should receive what type of therapy?
Psychotherapy
-
Adults with mild chronic, severe acute and severe chronic PTSD should receive what type of therapy?
psychotherapy or combo of psychotherapy and pharmacotherapy
-
These drugs have FDA approval for PTSD
-
These drugs should be reserved for patients who fail treatment with other medications
- MAOIs
- Mirtazepine
- Venlafaxine XR
-
Alternative treatments for PTSD
- Anticonvulsants/Mood Stabilizers - rec if co-morbid bipolar disorder. May reduce irritabilty and impulse control
- Gabapentin - may be useful in pts with co-morbid chronic pain
- Anti-adrenergic agents (clonidine, guanfacine, propranolol) - may reduce arousal, re-experiencing behaviors and dissociative sx
- SGAs - unclear (2nd line)
-
As effective as CBT for treatment resistant SAD
MAOI (phenelzine)
-
Second line therapy for SAD
- BZDs (clonazepam most studied)
- Best candidates - low risk for abuse with low risk for abuse who need acute relief or have falied other tx
-
Reduce perfomance related anxiety
- Beta-blockers
- Propranolol - 10-80mg/day
- Atenolol - 25-100mg/day
-
Last line therapy for SAD
- Gabapentin
- Side effects - dizziness and dry mouth
- Dose range - 900-3600mg/day in three divided doses
|
|
