NAPLEX 2026 - Anxiety Disorders

What drugs can cause anxiety?

Asthmatic Ants Bring Coffee; Devious Individuals Love Snorting Speedy Tea.

---

Albuterol (if used too frequently or incorrectly)

Antipsychotics (aripiprazole, haloperidol)

Bupropion

Caffeine, in high doses

Decongestants (sudafed)

Illicit drugs (cocaine, LSD, meth)

Levothyroxine (if therapeutic overdose occurs)

Steroids

Stimulants (amphetamine, methylphenidate)

Theophylline

What natural products may be used for anxiety?

St. John's wort - depression and anxiety

- strong CYP3A4 inducer, many DIs

- causes photosensitivity

- serotonergic, risk for serotonin syndrome

Valerian - anxiety and sleep

- may be contaminated with liver toxins, monitor liver function

Passionflower

• appears safe and is rated as “possibly effective”

Kava - relaxant

- can causes severe liver damage, not recommended

What medications are 1st line for treatment of anxiety? Dosing and onset?

SSRIs

- escitalopram (Lexapro)

- fluoxetine (Prozac)

- paroxetine (Paxil)

- sertraline (Zoloft)

---

SNRIs

- duloxetine (Cymbalta)

- venlafaxine ER (Effexor XR)

---

Most dosing will start at half the initial dose for depression

- start low and go slow

Will not provide immediate relief, takes at least 4 weeks at higher doses for a noticeable effect

NOTE:

Other SSRIs and SNRIs may be used off-label for anxiety disorder

What are the 2nd line options for treatment of anxiety?

Buspirone

- can use in combo w/ antidepressants (when there is a poor response)

- does not provide immediate relief, takes 2-4 weeks for effect

---

TCAs: amitriptyline and nortriptyline

- not FDA approved for anxiety

---

Hydroxyzine

- sedating antihistamine

- should not be used long term, use as needed

---

Pregabalin, gabapentin

- benefit in pts with anxiety and neuropathy

- immediate effects

What medication can help reduce symptoms of stage fright or performance anxiety?

Propranolol (Inderal LA/XL)

Buspirone CI

MAOI use within the past 14 days, use with Linezolid and methylene blue

Buspirone Warning

Risk of Serotonin Syndrome alone or with other serotonergic drugs

Buspirone: MOA

Unknown

Effect may be due to its affinity for 5-HT1A and 5-HT2 receptors

No potential for abuse, tolerance, or physiological dependence

Buspirone Drug Interactions

• Risk of serotonin syndrome is increases when used in combination with other serotonergic drugs

• Avoid grapefruit and grapefruit juice - increases buspirone levels

• Buspirone = major CYP3A4 substrate

Benzodiazepines: MOA

Enhances GABA (gamma-aminobutyric acid), an inhibitory neurotransmitter

- causes CNS depression, resulting in anxiolytic, anticonvulsant, sedative, and/or muscle relaxant properties

When are benzodiazepines used? What's the risk?

Provide fast relief - useful for short term treatment of acute anxiety

If taken long-term, pts can become addicted and develop tolerance

- due to risk, should only be used for 1 to 2 weeks and then d/c

- if used longer, taper off to avoid withdrawal

What benzodiazepines are preferred in patients over 65?

LOT: lorazepam, oxazepam, temazepam

• Lorazepam and Oxazepam for anxiety

• Temazepam for Insomnia

- undergo glucuronidation instead of liver metabolism -> less SEs (confusion, dizziness, falls)

What are the recommendations for safe use of benzodiazepines?

Benzos are highly sedating and often not preferred due to safety concerns

Anxiety:

- SSRIs and SNRIs preferred

- if used, consider BZD with longer half life and less risk of abuse (clonazepam and lorazepam)

---

Sleep:

- 1st line: non-pharm treatment

- 2nd line: non-BZD hypnotic (zolpidem)

- if used, consider temazepam

---

Elderly or pts with Liver Impairment:

- LOT

Seizures:

- injectable BZDs or diazepam rectal gel, can be administered by caregiver at home

Benzodiazepines: boxed warnings

Use with opioids can result in sedation, respiratory depression, coma, and death

Risk for abuse, misuse, and addiction, can lead to overdose or death

Continued use can lead to physical dependence

- taper slowly to avoid withdrawal — avoid abrupt discontinuation

Benzodiazepines CI

Severe liver disease (clonazepam and diazepam)

Alprazolam is contraindicated with strong CYP3A4 inhibitors

Benzodiazepines: warnings

CNS depression

Anterograde amnesia

Potential for abuse

Safety risks for pts 65+ (impaired cognition, delirium, falls/fractures)

Pregnancy - crosses the placenta — can cause birth defects and neonatal withdrawal symptoms

Benzodiazepines: side effects

Somnolence

Dizziness

Ataxia (lack of voluntary muscle coordination)

Other Notes about Benzodiazepines

Diazepam — lipophilic, fast onset, long half-life, high abuse potential

Alprazolam — fast onset, often abused due to its quick action

Lorazepam, Diazepam, Chlordiazepoxide — Commonly used for alcohol withdrawal syndrome

Midazolam - Used in acute care

What's the antidote for benzodiazepines?

Flumazenil