Ch. 67 Anxiety Disorders

Anxiety Disorder

Chronic condition characterized by fear, worrying, and physical symptoms (tachycardia, palpitations, SOB, Stomach upset, etc.)

Drugs that can cause anxiety

- Albuterol

- Antipsychotics

- Bupropion

- Caffeine

- Decongestants

- Illicit drugs

- Levothyroxine

- Steroids

- Stimulants

- Theophylline

Non-Drug Treatment

Cognitive Behavioral Therapy (CBT)

Natural products for Anxiety

- St. John's wort

- Valerian

- Passionflower

- Kava

St. John’s Wort

Use/Safety Issues

Use

• Depression

• Anxiety

Safety Issues

• Photosensitivity

• Serotonergic

Valerian

Use

• Anxiety

• Sleep

Kava

Use/Safety Issues

Use

• Relaxant

Safety Issues

• Liver damage

  • Not recommended

First line for anxiety

SSRIs & SNRIs

SSRIs and SNRIs must be (tapered/titrated)

• Will not provide immediate relief, takes at least __ weeks

• Titrated

• 4

Hydroxyzine (Vistaril)

Notes

• Sedating antihistamine

• Should not be used long-term

Pregabalin (Lyrica)

Gabapentin (Neurontin)

Notes

• Not FDA-approved for anxiety but has shown benefit in patients with anxiety and neuropathic pain

Second line for anxiety

- Buspirone

- TCAs (Amitriptyline, Nortriptyline)

- Hydroxyzine

- Pregabalin, Gabapentin

When might propranolol be used for anxiety?

Public speaking or some short term event that may cause acute anxiety (lowers HR and keeps patient calm)

Buspirone has affinity for

• 5-HT1A and 5-HT2 receptors

Buspirone

Contraindications/Warnings/Notes

Contraindications

• Do not use with MAO inhibitors

Warnings

• Risk of serotonin syndrome

Notes

• No potential for abuse, tolerance or physiological dependence

When are BZDs used for anxiety?

Short-term relief of acute anxiety

Due to risk of dependency, Benzodiazepines should only be used for ________ weeks and then DC'd.

1-2 weeks (If used longer than 10 days, they require a taper)

BZDs with longer half-lifes

- Clonazepam

- Oxazepam

- Temazepam

BZDs that are safe with liver impairment and preferred for use in the elderly due to less side effects?

LOT

- Lorazepam

- Oxazepam

- Temazepam

Benzodiazepines (List Them)

• Alprazolam (Xanax)

• Clonazepam (Klonopin)

• Diazepam (Valium)

• Lorazepam (Ativan)

BZDs

Boxed Warnings

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

• Risk for abuse, misuse and addiction

• Can lead to physical dependence

  • Abrupt discontinuation can cause withdrawal symptoms

BZDs

Containdications

• Severe liver disease

BZDs

Warnings

• CNS depression

• Anterograde amnesia

• Potential for abuse

• Safety risk in elderly patients

• Pregnancy

BZDs

Side Effects

• Somnolence

• Dizziness

• Ataxia

BZDs

Notes

• C-IV

• Commonly used for alcohol withdrawal syndrome

  • Lorazepam, Diazepam, Chlordiazepoxide

Benzodiazepine Antidote

Flumazenil

Alprazolam is CI'd with strong CYP_______ inhibitors.

CYP3A4

BZDs Onset

FAST

- Triazolam

- Temazepam

- Diazepam

INTERMEDIATE

- Alprazolam

- Clonazepam

- Lorazepam

SLOW

- Oxazepam