Drugs for Anxiety Flashcards
PHARMACOTHERAPY OF ANXIETY: KEY POINTS
An antidepressant, usually an SSRI, is the drug of first choice for anxiety.
SSRIs can be used to treat generalized anxiety disorder (GAD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), panic disorder (PD) and obsessive-compulsive disorder (OCD).
As with the treatment of depression, antidepressants may take several weeks to relieve anxiety.
Bupropion is less effective than other antidepressants for treatment of anxiety.
Benzodiazepines are effective for most forms of anxiety, but produce pharmacologic dependence and have limited benefit in OCD or PTSD; they are generally recommended only for short-term or intermittent use in anxiety disorders.
Antidepressants
GENERALIZED ANXIETY DISORDER
Antidepressants are considered first-line agents in the management of chronic GAD.
They have replaced benzodiazepines as the drugs of choice for chronic GAD due to a tolerable side effect profile, no risk for dependency, and efficacy in common comorbid conditions including depression, panic, obsessivecompulsive disorder, and social anxiety disorder.
Antidepressants reduce the psychic symptoms (e.g.,worry and apprehension) of anxiety with a modest effect on autonomic or somatic symptoms (e.g., tremor, rapid heart rate, and/or sweating).
All antidepressants evaluated have resulted in a similar degree of anxiety reduction.
The onset of antianxiety effect is delayed 2 to 4 weeks.
Venlafaxine and SSRIs usually are preferred over tricyclic antidepressants (TCAs) due to improved safety and tolerability.
Selection of a particular antidepressant agent generally is based on history of prior response, side effect profile, drug-interaction profile, cost, or formulary availability.
PANIC DISORDER
SSRIs are the drugs of choice for treatment of panic disorder.
A TCA or MAOI may be effective when an SSRI is not.
Benzodiazepines
GENERALIZED ANXIETY DISORDER
Benzodiazepines remain the most effective and commonly used treatment for short-term management of anxiety where immediate relief of symptoms is desired. Benzodiazepines are recommended for acute treatment of GAD when short-term relief is needed, as an adjunct during initiation of antidepressant therapy, or to improve sleep.
Benzodiazepines act quickly but carry the liability of physiologic and psychologic dependence. They can be reasonably used as an initial adjunct while SSRIs are titrated to an effective dose, and they can then be tapered over 4-12 weeks while the SSRI is continued.
PANIC DISORDER
Benzodiazepines often are used concomitantly with antidepressants, especially early in treatment, or as monotherapy to acutely reduce panic symptoms.
Benzodiazepines are not preferred for long-term treatment but may be used when patients fail several antidepressant trials. PD patients with comorbid depression should be treated with an antidepressant.
Alprazolam, although widely used, may cause rebound anxiety between doses and has been associated with a withdrawal syndrome, including seizures.
Buspirone
GENERALIZED ANXIETY DISORDER
Unlike benzodiazepines, buspirone does not have abuse potential, does not cause withdrawal reactions, and does not potentiate alcohol and sedative-hypnotic effects. However, it has a gradual onset of action (i.e., 2 weeks) and does not provide immediate anxiety relief.
Buspirone is considered a second-line agent for GAD due to inconsistent data regarding its efficacy.
SOCIAL ANXIETY DISORDER
SAD is a chronic disorder that begins in adolescence and occurs with significant functional impairment and high rates of comorbidity. The goal of acute treatment is to reduce physiologic symptoms of anxiety, fear of social situations, and phobic behaviors. Patients with comordid depression should have a significant reduction in depressive symptoms. The long-term goal is to restore social functioning and improve the patient’s quality of life.
SSRIs are considered the drugs of choice based on their tolerability and efficacy for SAD as well as comorbid disorders.
The onset of response for antidepressants is delayed and may be as long as 8 to 12 weeks.
Clomipramine
OBSESSIVE COMPULSIVE DISORDER
Fluoxetine
OBSESSIVE COMPULSIVE DISORDER
Fluvoxamine
OBSESSIVE COMPULSIVE DISORDER
Paroxetine
OBSESSIVE COMPULSIVE DISORDER
Sertraline
OBSESSIVE COMPULSIVE DISORDER
OBSESSIVE COMPULSIVE DISORDER
Goals of therapy for OCD include reduction in the frequency of obsessive thoughts and in the time spent performing compulsive acts and reduction in the degree of anxiety. Treatment for OCD might not completely eliminate obsessions or compulsions, but patients can feel remarkably improved with partial resolution of their symptoms.
Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline are all FDA- approved for OCD. Comparisons show no difference in efficacy between clomipramine and the SSRIs, but the SSRIs have a more benign adverse effect profile.
For highly anxious OCD patients, adding a benzodiazepine or an antipsychotic drug may be beneficial.
POST TRAUMATIC STRESS DISORDER
PTSD is manifested when a traumatic or life-threatening even results in intrusive anxiety-provoking thoughts or imagery, hypervigilance, nightmares and avoidance of situations that remind the patient of the trauma.
Antidepressants are the major pharmacotherapeutic treatment for PTSD. In addition to their efficacy in PTSD, these agents are also effective for concurrent depression and anxiety disorders.
**SSRIs** are the first-line pharmacotherapy of PTSD. Other antidepressants (e.g., venlafaxine, TCAs and MAOIs) can also be effective, but they have less favorable side-effect profiles.
Sertraline and paroxetine are both approved for the acute treatment of PTSD and sertraline is approved for the long-term management of PTSD.
PERFORMANCE ANXIETY
β-blockers, particularly those with higher lipophilicity (propranolol and nadolol), are used for performance anxiety, such as fear of public speaking. Their use is limited by adverse effects such as hypotension.
