anxiety dr g

True or False: 18-20% of the U.S. population has anxiety disorders

True

What medications can cause anxiety?

Stimulants (amphetamines, methylphenidate), corticosteroids (prednisone), thyroid medications, beta-agonists (albuterol), caffeine, decongestants (pseudoephedrine), some SSRIs/SNRIs initially

Withdrawal from which medications can cause anxiety?

Alcohol, benzodiazepines, barbiturates, opioids, nicotine

Symptoms of GAD besides excessive worry for 6 months

Restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance

Treatment of choice for mild GAD (GAD-7 score ≈10)

Psychotherapy (Cognitive Behavioral Therapy)

Which endocrine condition can cause anxiety?

Hyperthyroidism

Low vitamin D increases risk of what psychiatric disorders?

Depression and anxiety disorders

Four medication classes used to treat GAD

SSRIs, SNRIs, benzodiazepines, buspirone

Pharmacological properties of benzodiazepines

Positive allosteric modulators of GABA-A receptors that increase chloride influx causing CNS inhibition

Common benzodiazepine withdrawal symptoms

Anxiety, insomnia, tremor, sweating, tachycardia, seizures (severe cases)

Withdrawal symptoms are more severe with which BZDs?

Short-acting benzodiazepines because plasma levels drop faster causing stronger rebound symptoms

How long does proper tapering of long-term benzodiazepine use usually take?

Weeks to months (commonly 8-12 weeks or longer)

Which benzodiazepine commonly prescribed for anxiety has a short duration of action?

Alprazolam (Xanax)

Which BZD is considered long-acting without a long-acting active metabolite?

Clonazepam (Klonopin)

Potential issues with long-term benzodiazepine use

Dependence, tolerance, withdrawal, cognitive impairment, falls in elderly, abuse potential

Which BZDs are recommended for patients with compromised hepatic function?

Lorazepam, Oxazepam, Temazepam (LOT drugs)

Which BZD is better for IM injections and why?

Lorazepam because it has more reliable IM absorption

What drinks should be avoided with BZDs? Why?

Alcohol because of additive CNS and respiratory depression

Why are Valium and Xanax most likely to be abused?

Rapid onset and reinforcing effects

Which BZD is least likely to be abused? Why?

Oxazepam because it has slower onset

What is flumazenil (Romazicon) used for?

Benzodiazepine overdose reversal (GABA-A antagonist)

Should flumazenil be used in multiple drug overdoses?

No, it may precipitate seizures especially if other drugs are involved

Why would a patient experience withdrawal on alprazolam after carbamazepine is added?

Carbamazepine induces CYP3A4 which increases alprazolam metabolism and lowers its concentration

Precaution with the initial dose of SSRIs for panic disorder

Start at low doses because SSRIs can initially worsen anxiety or cause activation

Why is bupropion usually not used for anxiety disorders?

It increases norepinephrine and dopamine which can worsen anxiety

Buspirone (Buspar) is approved for which anxiety disorder?

Generalized Anxiety Disorder (GAD)

What is the issue with Buspar 10 mg TID PRN anxiety?

Buspirone requires 2-4 weeks to work and is ineffective PRN

MOA of hydroxyzine for anxiety

H1 antihistamine causing CNS sedation

Common side effects of hydroxyzine

Sedation, drowsiness, dry mouth, anticholinergic effects

Which anxiety disorder is often mistaken for a myocardial infarction in the ED?

Panic disorder

Symptoms of panic attacks similar to MI

Chest pain, shortness of breath, palpitations, sweating, dizziness, nausea

Issue with long-term benzodiazepine use for anxiety

Tolerance, dependence, withdrawal, cognitive impairment

Medication class recommended for long-term treatment of panic disorder

SSRIs or SNRIs

Indication for Anafranil (clomipramine)

Obsessive-Compulsive Disorder (OCD)

Luvox (fluvoxamine) FDA-approved for which disorder?

Obsessive-Compulsive Disorder (OCD)

Best long-term treatment for PTSD

Trauma-focused psychotherapy (exposure therapy)

Why is PTSD therapy difficult during early sessions?

Patients must relive traumatic memories which increases distress initially

Off-label medication for PTSD nightmares and flashbacks

Prazosin

Most common phobia

Social anxiety disorder (social phobia)

How does propranolol help social anxiety?

Reduces physical symptoms such as tachycardia, tremor, and sweating

True or False: Bupropion is commonly used for anxiety disorders

False

FDA warning for gabapentin misuse

Risk of misuse, abuse, and respiratory depression especially with opioids

Why can patients with alcohol use disorder tolerate high doses of BZDs?

Cross-tolerance due to both acting on GABA-A receptors

What is cross tolerance?

Tolerance to one drug that results in tolerance to another drug with a similar mechanism

Which benzodiazepines do not need grapefruit juice warnings?

Lorazepam, Oxazepam, Temazepam because they are not metabolized by CYP3A4

35. Explain why SSRIs and SNRIs should be started at lower doses for anxiety disorders.

Explain why SSRIs and SNRIs should be started at lower doses for anxiety disorders.

To avoid initial activation and worsening anxiety symptoms