Exam II Study Materials for DPT VI with Focus on Generalized Anxiety Disorder and Pharmacological Interventions

DSM 5 Diagnosis: GAD

at least 6 months of symptoms, difficulty controlling the worry

presence of at least 3 symptoms: feeling keyed up or on edge, becoming easily fatigued, mind going blank, irritability, muscle tension, sleep disturbance

Clinical Presentation of GAD

irritability

restlessness

excessive worry

racing thoughts

sweating/blushing

tachycardia, arrhythmias

chest pain, muscle tightness, N/V/D

decreased social and occupational function

GAD-7 5-9

mild

GAD-7 10-14

moderate

GAD-7 > 15

severe

DSM5 Panic Disorder

recurrent unexpected panic attacks with at least 1 of the attacks being followed by a month or longer of at least 1 of the following:

constant concern about having another one

being anxious about implications of attack

maladaptive change in behavior designed to avoid it

Panic Attacks

spontaneous, unexpected, transient period of intense fear (lasts 20-30 minutes)

at least 4 of the following symptoms:

palpitations, diaphoresis, trembling, SOB, choking feeling, chest pain, paresthesia, chills/hot flashes, fear of dying, derealization, dizziness/faintness, fear of going crazy

Panic Attack vs Disorder

attack= single event

disorder = several attacks + persistent fear ( > 1 mo)

Risk factors for social anxiety disorder

over-protection from parental control, early childhood anxiety disorders, life stressors, psychiatric comorbidities, adverse life experiences

DSM-5 SAD

significant anxiety or fear about at least one social situation where the individual is exposed to possible scrutiny by others

fears display anxiety symptoms or act in a way that will be negatively assessed

anxiety, fear, avoidance is persistent with duration of 6 months or longer

Clinical Presentation of SAD

fears: embarrassment, humiliation, scrutinized by others

feared situations: public speaking, eating or drinking in front of others, interacting with authority figures

physical: blushing, butterflies, diarrhea, sweating, tachy

Clinical Presentation of PTSD

intrusion: feeling that traumatic event is recurring, recurrent, disturbing dreams of event

avoidance: avoidance of thoughts feelings or conversations and reminders

reactivity: decreased concentration, easily startled, reckless behavior

mood/cognition: inability to recall important aspects of trauma, negative expectations, distorted cognitions

Short Term Goals of anxiety disorders

reduce symptoms frequency and severity

improve function

Long Term Goals of anxiety disorders

symptom remission

no functional impairment

improved quality of life

What is first line for anxiety disorders?

SSRI/SNRIs

Counseling Points for SSRIs and SNRIs

initial symptom improvement takes at least 2-4 weeks, may take up to 8 weeks

adequate trial: 12 weeks

titrate to optimal dose

avoid abrupt discontinuation

What anxiety disorders does pregabalin have efficacy for?

generalized and social anxiety disorder

Onset of effect of pregabalin

< 1 week

works a lot faster, and can be considered 1st line option for GAD

Adverse effects of Pregabalin

edema

sedation

vision changes (dose-dependent)

weight gain

Starting Dose of Pregabalin

150 mg daily in 3 divided doses (50 mg TID)

take after a meal to increase bioavailability

target dose: 150-600 mg/day; increase by 150 mg/day each week

Precautions and warnings for Pregabalin

risk of respiratory depression with opioids and other medications

At what CrCl should you decrease dose of pregabalin?

< 60 mL/min

Drug interactions of pregabalin

opioids, alcohol, CNS depressants

What is buspirone FDA approved for?

generalized anxiety disorder

Place in therapy for Buspirone in GAD

effective 2nd line monotherapy or augmentation in GAD

Initial dosing for buspirone

5 mg BID/TID

titrate 5 mg every 2-3 days

typical dose: 15 mg BID

When is busiprone NOT recommended for use?

those with hepatic or renal impairment

Adverse effects of buspirone

generally well tolerated

nausea/dizziness/headache

Drug Interactions of Buspirone

CYP3A4 inhibitors and inducers

Warnings/Precautions of Buspirone

may cause akathisia

Counseling Points of Buspirone

delayed onset of action, similar to SSRIs/SNRIs

not a PRN medication - needs to be taken consistently for best effect

What is hydroxyzine approved for?

generalized anxiety disorder

What is hydroxyzine usually used for?

often "as needed" due to onset of action (effects seen within 30 minutes)

considered 2nd line therapy in GAD, could also be useful for insomnia with anxiety

Dosing for Hydroxyzine

25 mg BID scheduled OR prn

Dosing Adjustments for Hydroxyzine

ELDERY, due to adverse effects must use lower doses

hepatic impairment: expand to every 24 hours

Warning/Precautions for hydroxyzine

BPH

dementia

constipation

narrow angle glaucoma

CNS depression

elderly

Adverse effects of Hydroxyzine

anticholinergic (constipation, blurred vision, dry mouth), sedation

Drug Interactions of Hydroxyzine

alcohol, BZDs, opioids, TCAs, benztropine, other antihistamines

What TCAs are used in anxiety disorders?

imipramine, clomipramine, amitriptyline

Place in therapy for TCAs in anxiety disorders

useful when SSRI/SNRIs are ineffective or unable to be tolerated by patients

Why are TCAs limited in use in anxiety disorders?

poor tolerability and risk of serious adverse reactions

Which MAOI is most commonly used in anxiety disorders?

phenelzine

Place in therapy for phenelzine

at least 3rd line agent

only in patients refractory to standard treatment and augmentation

literally last line

Can SGAs be used as monotherapy in anxiety disorders?

NEVER EVER EVER

What SGAs are most effective/studied in anxiety disorders?

olanzapine, risperidone and quetiapine

Place in therapy for SGAs in anxiety disorder

viewed as alternative and or adjunct therapy in TREATMENT RESISTANT anxiety disorders

Which SGA works the best in GAD and PTSD?

quetiapine

Which SGA works best in SAD

olanzapine

What two drugs can be used as add-on therapy for sleep disturbances (nightmares) in PTSD?

prazosin and clonidine

Prazosin

alpha 1 agonist, used for sleep disturbances in ptsd

dose at bedtime: 1-16 mg/day

Clonidine

alpha 2 agonist, used for sleep disturbances in ptsd

dose variable: 0.2-0.6 mg daily, divided doses

Side effects of prazosin

orthostatic hypotension, dizziness, palpitations, first dose syncope

Side effects of clonidine

hypotension, dry mouth, dizziness, syncope, rebound hypertension

Benzodiazepines

generally utilized as add-on or second line (typically not used as monotherapy)

can be useful in acute phase management of anxiety (2-3 weeks until full effect of antidepressants)

Are benzodiazepines useful in ptsd?

nope

Adverse Effects of Benzodiazepines

sedation, psychomotor impairment, impaired cognition, vision changes, hypotension, dry mouth, amnesia, coma, respiratory depression

Patients who take BZDs long term...

higher risk for memory and concentration problems, daytime fatigue, falls and fractures, increased risk of having a moto vehicle accident while driving

What are some additional concerns with benzodiazepines?

misuse, addiction and overdose

What two benzodiazepines are preferred in older adults?

lorazepam and oxazepam

Are all benzodiazepines dosed the same?

no! there is a chart that you can base doses off of lorazepam

Which benzodiazepines are short acting?

alprazolam

lorazepam

oxazepam

Which benzodiazepines are long acting?

clonazepam

chlordiazepoxide

diazepam

PK/PD result in elderly with BZDs

increases drug exposure

Common Symptoms of Benzodiazepine Withdrawal

anxiety, insomnia, restlessness, muscle tension, irritability

SEIZURES

Seizures in BZD withdrawal

usually occurs with short half life agents and occur within 3 days of abrupt discontinuation

can occur up to 1 week or later after abrupt discontinuation in longer half life agents

Who is at risk to experiences seizures with BZDs withdrawal?

higher doses

longer duration of use

combination of other agents that lower seizure threshold

Discontinuation Principle of BZD

10-25% reduction every 1-2 weeks UNTIL 50% of dose is reached

pause and stabilize at 50% of dose

then once stabilized, resume but utilize lower % reduction and space out taper

SSRI/SNRIs are useful with co-morbid

MDD

Pregabalin is useful with co-morbid

chronic pain

TCA may be useful with co-morbid

insomnia

DSM-5 Diagnosis for OUD and AUD

decline in functioning: failure to fulfill major role, important social, occupational or recreational activities are reduced or given up

loss of control: taking larger amounts or for a longer time period, persistent desire, trying to obtain, craving

continued use despite negative consequences

OUD (opioid use disorder) AND AUD (alcohol use disorder)

problematic pattern of substance use with clinically significant distress or impairment with at least 2 of the following within a 12 month period

Short Term goals of treatment for OUD

eliminate withdrawal and cravings

reduce immediate risk associated with opioid misuse

Long Term Goals of Treatment for OUD

increase social functioning

remission of opioid addiction

What medications can be used for OUD?

methadone

buprenorphine/naloxone (suboxone)

naltrexone

Onset of Action of Methadone

within hours

but a FULL opioid agonist (so could have more withdrawal)

What is the restriction of methadone?

controlled substance that has to be obtained from a clinic

must be prescribed, dispensed, and administered

Patient Considerations for Methadone

long half life (once daily)

consider for pregnant patients

good for those who need structured environment

no withdrawal required to start treatment

What is required to be offered for every opioid use medication?

naloxone

Safety Monitoring for Methadone

RR, HR, BP, QTc, urine drug screens

Counseling Points for methadone

avoid alcohol and BZD

if admitted, dose and adherence needs to be confirmed by OTP

Patient Considerations for Suboxone

can be dispensed at local pharmacy

long half life

multiple formulations available

standard induction requires mild-mod opioid withdrawal

Counseling Points for Suboxone

avoid acidic drinks and nicotine prior to dose

avoid alcohol and BZDs

CAN split tablet or film

HOLD tablet or film under tongue for several minutes until it dissolves

Microinduction Theory with Suboxone

gradual increase of buprenorphine dose will incrementally displace full agonist but not enough to precipitate withdrawal

once target dose achieved (16 mg/day), full agonist can be displaced and stopped

Patient Considerations for Naltrexone

non-opioid agonist option (for those wanting to avoid opioids in treatment)

long acting INJECTABLE

no abuse potential

approved for OUD and AUD

Warnings and Precautions for Naltrexone

acute hepatitis

severe hepatic impairment

depression and suicidal thoughts

DO NOT USE IN PREGNANT PATIENTS

caution in decompensated cirrhosis and those with renal impairment

Initiation of Naltrexone

MUST be off opioids for a minimum of 7-10 days

onset: 24 hours (IM)

Counseling Points for Naltrexone

opioid free for > 7-10 days

alert all providers that you are on this

avoid opioids for pain management

injection is every 28 days

ensure have emergency card

must be observed taking this medication for OUD

Does naltrexone reduce withdrawal symptoms?

no

Which MOUD has mortality benefits?

buprenorphine and methadone

Goals of Treatment for Maintenance of AUD

decrease number of days drinking, heavy drinking, and drinks per day

minimize physical, psychological, financial, and social harm

What are the three drugs that can be used for AUD?

acamprosate, disulfiram, naltrexone

Acamprosate

TID dosing

oral tablet

adverse events: diarrhea, insomnia, anxiety, depression, weakness

Contraindications for Acamprosate

CrCl < 30 mL/min

Warnings and Precautions for Acamprosate

suicidal ideation and depression, alcohol withdrawal (DOES NOT TREAT), renal impairment

Disulfiram

250 mg daily, oral tablet

Contraindications for Disulfiram

severe myocardial disease

use of alcohol products within 14 days after discontinuing

psychosis

recent or current use of metro

How long does disulfiram effect last after last dose?

1-2 weeks

When should you NOT initiate disulfiram?

at least 12-24 hours after ingesting alcohol

BAL of 0 required

Adverse effects of disulifram

disulifram reaction: warmness and flushing of skin, increased HR, palpitations, decreased BP