CLINPHARM: PT 4 - 07 Anxiety Disorders

• weight gain

• teratogenic 

• drowsiness

3 side effects of paroxetine (SSRI)

• w___ g___

• t___

• d___

• QT prolongation

• thrombocytopenia

2 side effects of citalopram (SSRI)

• Q___ p___

• t___

fluoxetine and sertraline

2 SSRIs that cause insomnia or restlessness

• f___

• s___

• arrhythmia

• QT interval

avoid citalopram for patients with a___ and if they use drugs that can prolong Q___ i___

• GAD, SAD, panic disorder, OCD

• 2 weeks

• 4-6 weeks

SNRI

• for G___, S___, p___ disorder, O___

• monitor every ___ weeks for the first ___-___ weeks of treatment

• increased BP (due to increase NE levels)

SNRI

• additional side effect: increased ___

hypertension

SNRIs are contraindicated for patients with h___

• Venlafaxine

• Duloxetine

2 SNRI drugs

• V___ XR (Effexor XR)

• D___ (Cymbalta) 

• Effexor XR

• Cymbalta 

2 SNRI drugs

• Venlafaxine XR (E___ XR)

• Duloxetine (C___) 

tricyclic antidepressants (TCA)

2nd line agent (antidepressant) due to its high toxicity and ADE rate

once a day

TCA dosing: ___ a day

tricyclic antidepressants (TCA)

these are indicated if patient is unresponsive to 1st line antidepressants

• Imipramine

• Clomipramine

• Amytriptyline

3 TCA drugs

• I___ (Tofranil) 

• C___ (Anafranil)

• A___ (Elavil)

• Tofranil

• Anafranil

• Elavil

3 TCA drugs

• Imipramine (T___)

• Clomipramine (A___)

• Amytriptyline (E___)

Clomipramine (Anafranil)

TCA drug that is more effective in OCD

• orthostatic hypotension

• anticholinergic

• cholinergic

• arrhythmia

TCA side effects

• sedation

• o___ h___

• a___ effect

• weight gain

• c___ rebound

• a___ (overdose)

• sexual dysfunction

• serotonin

• norepinephrine 

• alpha-1

• histamine

• muscarinic

5 receptors that TCA blocks

• s___

• n___

• a___

• h___

• m___

histamine

TCA side effect

• blocking ___ receptor leads to sedation 

alpha-1

TCA side effect

• blocking ___ receptor leads to orthostatic hypotension  

muscarinic

TCA side effect

• blocking ___ receptor leads to anticholinergic effects 

monoamine-oxidase inhibitors (MAOIs)

potent antidepressants but rarely used for potential severe interactions with drugs and dietary restrictions

• moclobemide

• phenelzine

2 MAOI drugs

• m___

• p___

monoamine-oxidase inhibitors (MAOIs)

antidepressants that are rarely used in practice

moclobemide

reversible MAOI

moclobemide and phenelzine 

MAOIs used for SAD following failure to SSRI

phenelzine

irreversible MAOI

uncontrolled hypertension

avoid giving MAOIs to patients with uncontrolled h___

benzodiazepine

sedative/hypnotic, anxiolytic, amnesic, muscle relaxant, anticonvulsant

• sedative/hypnotic

• anxiolytic

• amnesic

• muscle relaxant

• anticonvulsant 

benzodiazepine is used as:

• s___/h___

• a___

• a___

• muscle r___

• a___

benzodiazepine

frequently prescribed for the treatment of acute anxiety

benzodiazepine

for this drug, improvement occurs in the 1st 2 weeks of therapy (shorter than SSRIs and SNRIs)

benzodiazepine

more effective for somatic and autonomic symptoms of GAD

benzodiazepine

2nd line for anxiety disorders

barbiturate

barbiturate or benzodiazepine: duration of opening; longer time for chloride ion channels to open

benzodiazepine

barbiturate or benzodiazepine: frequency of opening

• CNS depression

• sedation

• tolerance

• psychomotor

• anterograde

benzodiazepine side effects

• C___ depression

• s___

• t___

• disorientation

• p___ impairment at high doses

• confusion

• aggression

• excitement

• a___ amnesia

• alcohol

• CNS depressant

• antihistamine

• opioids

benzodiazepine drug interactions

• a___

• C___ depressant drugs

• a___, especially 1st generation 

• o___ 

• pregnant

• lactating mothers

benzodiazepine contraindications

• p___

• l___ mothers

• recurrence or relapse

• rebound symptoms

• withdrawal

benzodiazepine discontinuation can lead to (3)

• r___ or r___

• r___ symptoms

• w___

• 24-48 hours

• severe symptoms

onset of benzodiazepine

• short elimination half life: onset of symptoms occur ___-___ hours after last dose with mild/severe withdrawal symptoms

• 3-8 days

• mild symptoms

onset of benzodiazepine

• long elimination half life: onset of symptoms occur ___-___ days after last dose with mild/severe withdrawal symptoms

• Imipramine, Valproic acid, Buspirone

benzodiazepine discontinuation strategies

1. gradual dose reduction

2. adjunctive therapy: I___, V___ a,___, B___

• weekly

• 2-4 weeks

benzodiazepine dosing

• start low

• dose adjustments can be made w___

• acute treatment: benzodiazepine-free period (___-___ weeks is recommended)

• alprazolam

• oxazepam

• lorazepam

3 short acting benzodiazepines

• A___

• O___

• L___

• Diazepam

• Clonazepam

• Chlordiazepoxide

• Clorazepate

4 long acting benzodiazepines

• D___

• C___

• C___

• C___

Diazepam

benzodiazepine to use if faster onset of action and more sustained effect is desired

short-acting benzodiazepines (alprazolam, oxazepam, lorazepam)

benzodiazepine to use for short/acute relief only

• 24 hours

• multiple

short acting benzodiazepines half elimination half life less than ___ hours, requiring m___ dosing intervals

Buspirone (Buspar)

2nd line agent for GAD

Buspirone (Buspar)

drug for short-term treatment of anxiety

• twice or thrice a day

Buspirone (Buspar)

• dosing: ___ a day or ___ a day

2 weeks or more

Buspirone (Buspar)

• onset: ___ weeks or more

anxiety

Buspirone (Buspar) is not useful for cases that need rapid relief of a___ as effect is seen after 2 weeks of consistent use

• partial agonist

• full agonist

Buspirone (Buspar) MOA

• ___ agonist at postsynaptic 5-HT1A receptor

• ___ agonist at at presynaptic 5-HT1A receptor

Hydroxyzine (Atarax)

sedating antihistamine

Hydroxyzine (Atarax)

2nd line agent for GAD, short-term treatment specially when sedation is desired

4x a day

Hydroxyzine (Atarax)

• dosing: ___ a day

Hydroxyzine (Atarax)

Clinical evidence only supports its use for GAD for up to 4 weeks of treatment if sedation is required

Pregabalin (Lyrica)

anticonvulsant that is used as 2nd-line agent for GAD, SAD

Pregabalin (Lyrica)

anticonvulsant that is used as 2nd-line agent for GAD either alone or adjunct with SSRI/SNRI

Pregabalin (Lyrica)

drug that has anxiolytic effect similar to lorazepam, alprazolam, and venlafaxine

1-2 weeks

for Pregabalin (Lyrica), anxiolytic effect is seen after ___-___ weeks

not cause dependence

Pregabalin (Lyrica) advantage over benzodiazepine is that it does not cause d___

SSRI

1st drug option for GAD, SAD, Panic disorder, PTSD, OCD

once a day

SSRI dosing

• ___ a day

• Citalopram (Celexa)

• Escitalopram (Lexapro)

• Paroxetine (Paxil)

• Fluvoxamine (Luvox)

• Sertraline (Zoloft)

5 SSRI drugs

• C___ (Celexa)

• E___ (Lexapro)

• P___ (Paxil)

• F___ (Luvox)

• S___ (Zoloft)

Escitalopram (Lexapro)

SSRI - 1st line for SAD

Paroxetine (Paxil)

SSRI - 1st line for GAD

Sertraline (Zoloft)

SSRI - 1st line for GAD and SAD