PSYC 08: Anxiety Pharmacology + Therapeutics

Benzodiazepines

1) What line of therapy for anxiety, why?

2) NOT used in what anxieties (2)

3) Most effective for which one: Somatic, Cognitive, or Psychological symptoms?

4) MOA: ____ inhibition of ____ by binding ____ receptor to ___ neuronal excitability

5) Side effects

6) Risk of what

7) Drug interactions

8) What can sudden discontinuation cause (3)

9) When can seizures occur

1) Second, due to safety profile

2) PTSD, OCD

3) Somatic

4) Enhances inhibition of GABA by binding GABA receptor to reduce neuronal excitability

5) CNS depression (drowsiness, sedation, motor + memory impairment)

6) Abuse, dependence, withdrawal

7) CNS depressants (Alcohol, opioids, antihistamines)

8) Sudden discontinuation so taper well:

• Rebound anxiety

• Anxiety recurrence

• Withdrawal symptoms

  • Insomnia, muscle tension, irratibility, hallucinations, seizures, tinnitus

9) Seizures can occur within 3 days - 1 week (depends on half life)

Diazepam

Clonazepam

Long acting BZD

Alprazolam

Lorazepam

Intermediate acting BZD

Triazolam

Short acting BZD

Anticonvulsants

1) Name two medications in this category

2) Which line of therapy is it

3) What is it used for

4) What’s wrong with it being only effective at high doses

5) MOA

6) Side effects

7) Out of the 2 drugs, which one has potential for abuse so avoid in SUD

8) DDIs

1) Pregablin, Gabapentin

2) Second

3) GAD, SAD

4) Causes a lot of sedation, higher risk of ADRs

5) MOA:

• Binds voltage gated Ca channels to reduce Ca influx

  • REDUCES FIRING OF HYPEREXCITED NEURONS

6) CNS effects (Drowziness, dizziness, fatigue, ataxia, impaired vision)

7) Pregablin

8) CNS depressants

Azapirones

1) Name the drug in this category (1)

2) What line of therapy is this

3) Which anxiety is it used

4) MOA

5) Side effects

6) DDIs

1) Buspirone

2) Second

3) GAD

4) MOA:

• Agonist of 5-HT1A receptors

• Increases “brake” of autoreceptors

• Less serotonin is released; decreases anxiety symptoms

5) Fatigue, headache, agitation

6) CYP3A4 inducers/inhibitors

Beta Blockers

1) Name the 2 that we use for anxiety

2) What type of anxiety is it used for (be specific)

3) MOA

4) Side effects

1) Propranolol, Atenolol

2) SAD —> Public Performance Situations ONLY

3) MOA:

• Antagonizes beta-1 adrenergic receptors to block autonomic symptoms (rapid heart rate, sweating, blushing, tremor)

4) Hypotension, bradycardia

Antihypertensives

1) Which drug is used?

2) What type of anxiety is it used for to do what

3) MOA: ____s ____ ___ receptors to reduce ____ outflow in the brain

4) ADRs

5) DDI (2)

6) When should you take it (what time of day) and why

1) Prazosin (short half life)

2) PTSD —> Improve sleep / Reduce nightmares & terrors

3) Antagonizes alpha-1 adrenergic receptors to reduce sympathetic outflow in brain

4) Decreased BP, orthostatic hypotension, dizziness

5) Other antihypertensives or PDE5 inhibitors (sildenafil, tadalafil)

6) Night, it’s poorly tolerated (the dizziness)

Antihistamines

1) Name the drug thats used

2) What type of anxiety is it used for

3) What line of therapy

4) MOA

5) ADR

1) Hydroxyzine

2) GAD

3) Second line

4) Potent INVERSE H1 receptor antagonist; and some minor 5HT2 receptor antagonism

5) Sedation, anticholinergic effects

Atypical Antipsychotics: Quetiapine

1) Used in what type of anxiety

2) What line of therapy

3) MOA

4) Drug interactinos

1) GAD

2) 2nd

3) D2 receptor and 5HT2a receptor antagonism

4) CNS depressants + CYP 3a4

Cannabinoid (CBD)

1) CBD or THC for anxiety

2) ^ interacts w/ many receptors including cannabinoid recptors and it __gonizes ____ receptors which leads to anxiolytic activity

3) Is it recommended

1) CBD

2) AGONIZES 5HT1A receptors

3) No

GAD-7 moderate anxiety score

10-14

GAD-7 severe anxiety score

15+

How long should you treat for? Is it longer or shorter than MDD?

12-24 months

—> Longer than MDD which is 6-12

Why should you start low and titrate up (1-2 week intervals for 4-6 weeks)

Patients w/ anxiety disorders often have increased sensitivity to ADRs

FIRST LINE THERAPY FOR GAD, PD, PTSD (2)

• SSRI

• SNRI

FIRST LINE THERAPY FOR SAD

• SSRI

• SNRI

• ~Pregablin/Gabapentin (Anticonvulsants)

First line therapy for OCD

SSRI; High doses

Which 3 SSRIs are NOT the best choice of SSRIs when it comes to anxiety and why specifically for each one

Fluoxetine = Stimulating

Fluvoxamine = Sedating

Paroxetine = Anticholinergic

Order of treatment recommendations

1) Non-Pharm

2) Psychotherapy

3) Pharm

Social Anxiety Disorder:

Why do long term studies show that psychotherapy is better than pharmacotherapy

Because the condition is chronic. Rx should not be chronic.

In which anxiety disorder is the combination of psychotherapy AND pharmacotherapy superior to either modality alone

Panic Disorder

PTSD: When should you start medication/treatment

Week 1-4 = EMOTIONAL SUPPORT ONLY

Week 4 + = Start medication/treatment (psychotherapy)

PTSD

1) Name 2 medications that can be used to help with symptoms from PTSD and specify what symptoms it helps

3) Which medication is NOT recommended in this population and why

1) Trazodone = Insomnia

2) Prazosin = Nightmares

3) DO NOT USE BZD (lack of efficacy + risk of SUD in PTSD)

For which condition is psychotherapy + pharmacotherapy combo superior to pharmacotherapy ALONE but NOT to psychotherapy alone

OCD

Response to anxiety treatment is defined as > __% improement in score on validated scale

50%

Pregnancy + Lactation population

1) Psychotherapy is always first line; however, if it fails we use:

2) What to AVOID and why

1) Sertraline, Escitalopram, Citalopram

2) BZDs —> Increase risk of orofacial cleft + neonatal withdrawal

Pediatric Populations

1) Evidence for antidepressant use in PTSD?

2) Which 3 meds are used off label

3) Why are BZDs not recommended

4) Black box warning of what for kids

1) No

2) Fluoxetine, Sertraline, Paroxetine

3) Can cause paradoxical excitement

4) Increase risk of suicidality in kids

Geriatrics

1) Monitor/caution SSRIs because elderly are more susceptible to what 3 things

2) Increased risks of ___ and ___

3) Which SSRI should you avoid and why

1) Bleeding, QTc prolongation, SIADH (Syndrome of inappropriate antidiuretic hormone)

2) Increased risk of falls and fractures

3) Paroxetine; strongly anticholinergic