What are the risk factors for anxiety?
- Women - Age: develops prior ro age 30 - Family history of anxiety or depression - Life stressors
Pathophysiology of Anxiety?
- Abnormal NT functioning in the amygdala, GABA, NE, Serotonin - Corticotrophin releasing factor - Cholecystokinin - Glutamate - Substance P
Classifications of anxiety
- Generalized anxiety disorder - Panic disorder - Social anxiety disorder - Obsessive-compulsive disorder - Post traumatic stress disorder - Specific phobias
Nonpharm treatment of Anxiety?
- Psychotherapy - Cognitive behavioral therapy - Meditation - Exercise - Avoid caffeine, stimulants, diet pills, or other meds that cause anxiety - Identify and remove causes of anxiety
Pharmacologic treatment of anxiety
- Antidepressants SSRI, ANRIs, TCAs - Benxodiazepines - Buspirone - Hydroxyzine - Pregabalin
GAD 1st and 2nd line?
1st: SSRIs/SNRIs 2nd: Benzos as needed, buspirone
Panic disorder first line?
SSRIs may need scheduled benzos for 2-4 weeks May need PRN benzo for attacks
OCD? 1st line and 2nd line?
1st: SSRIs (high dose) or CBT or both 2nd line: Clomipramine or antipsychotic augmentation
Social anxiety 1st and 2nd line
1st SSRI/ SNRIs 2nd: Benzos Beta blockers for performance anxiety
PTSD 1st line? Adjunctive agents? What not to give?
1st SSRIs, SNRIs, Add Prazosin or antipsychotic or mood stabalizer No benzos
Specific phobia treatment?
SSRIs first line for GAD, PD, OCD, Social anxiety, PTSD
- Start at a lower dose - Can initially cause anxiety - Slower onset than benzos - Need higher dosages for OCD
You need a higher when starting an SSRI with what disease?
Escitalopram is approved for the treatment of?
Approved for GAD
Fluoxetine is approved for?
approved for PD
Fluvoxamine approved for the treatment of?
Paroxetine approved for the treatment of?
treatment of GAD, OCD, PD, PTSD, SAD
Sertraline Approved for the treatment of?
treatment of OCD, PTSD
Venlafaxine XR approved for the treatment of?
GAD and SAD
Duloxetine treatment of?
What are the SEs of SSRIs?
S-Stomach (N/V/D) S- Sexual dysfunction R- Restlessness, Jitteriness I- Insomnia Headache, Weight gain, withdrawal from abrupt discontinuation
Antidepressant tips - If one SSRI/SNRI is ineffective what should be done? - Patients often become tolerant to what? - These medications require? - How many weeks does it take to see response? - When you stop an SSRI how do you do it?
- You should try another one - SEs usually stop within a few weeks expect for Sexual Dysfunction - These require daily administration - Often take 4 weeks or more to see effect - Upon discontinuation you have to taper
Benzo are ___ line or adjunct for? Most effective for? Shouldnt be used to treat?
2nd line for anxiety Most effective for acute symptoms Not effective for OCD or PTSD
What benzos have a very fast onset?
Alprazolam, Diazepam (super fast)
LOT what are the drugs and what are they good for?
Temazepam, Lorazepam, Oxazepam Good for the liver Little to no CYP metabolism
Benzos with slow onset?
Oxazepam, Clonazepam, Lorazepam
Im administration what benzo?
Most benzos are substrates for?
Substrate of 2C19
Inhibitors of CYP3A4
Amiodarone, Azoles, AIDS protease inhibitors, Cimetidine, Ciprofloxacin, Clarithromycin/Erythromycin, CCBs (Diltiazem/Verapamil) Fluvoxamine, Grapefruit, Nefazodone