Pharmacotherapeutics > Anxiolytics CA2 > Flashcards

Anxiolytics CA2 Flashcards

(36 cards)

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1
Q

Brief description of anxiety-related disorders

A

Generalised Anxiety Disorder: excessive anxiety and worries for >6 months

Panic disorder: anticipatory anxiety and recurrent panic attacks

Obsessive Compulsive Disorder (OCD): occasional thoughts/impulses that cause anxiety, followed by compulsive behaviours to relieve that anxiety.

Post-traumatic stress disorder (PTSD): re-experiencing of trauma, persistent avoidance and increased arousal.

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2
Q

Etiology and pathophysiology of anxiolytics

A
  • Fear circuit is regulated by the amydala
  • Worry circuit is regulated by the cortico-striatal-thalamic cortical (CSTC) loop.
  • Neurotransmitters involved:
    » Serotonin
    »> Pathological fear/anxiety is related to the over-activation of the amygdala.
    »> High serotonin output -> increased anxiety
    » GABA
    »> Inhibitory neurotransmitter
    »> Low levels -> high anxiety
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3
Q

Medical conditions associated with anxiety

A

cardiovascular: heart failure
endocrine: hyperthyroidism
neurologic: dementia, delirium
pulmonary: asthma, COPD

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4
Q

Clinical presentation of GAD

A
  • Excessive anxiety and worry ≥ 6 months
  • 3 or more of the following symptoms:
    1. Restlessness or feeling on edge
    2. Being easily fatigued
    3. Difficulty concentrating or mind going blank
    4. Irritability
    5. Muscle tension
    6. Sleep disturbance (insomnia, restless unsatisfying sleep)
  • Can cause significant functional impairment
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5
Q

Clinical presentation of panic disorder

A
  • Recurrent unexpected panic attacks, and ≥1 of the panic attacks has been followed by ≥1 month of ≥1 of the following:
    » Persistent anticipatory anxiety of having additional panic attacks
    » Worry about the implications of the panic attack
    » Significant change in behaviour related to the panic attacks.
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6
Q

Clinical presentation of social anxiety disorder

A
  • Marked and persistent fear of ≥1 social/performance situations, where the person is exposed to unfamiliar people or possible scrutiny by other. He/she acts in a way that will be humiliating or embarrassing.
  • Duration: >6 months
  • Social situations are avoided, impairs functioning.
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7
Q

Clinical presentation of PTSD

A
  • Person is exposed to a major stressor: e.g. death, threatened death, violence
  • Traumatic experience is persistently re-experienced by the person
  • Persistent, effortful avoidance of distressing, trauma-related stimuli post event
  • Negative alterations in mood and cognitions
  • Trauma-related alterations in arousal or reactivity
    » Irritable and aggressive behavior
    » Self-destructive etc.
  • Persistence of symptoms, could lead to functional impairment
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8
Q

Assessment of anxiety disorder

A
  • Clinician-rated: Hamilton Anxiety Scale (HAM-A)
    » Significant anxiety: Score 18-20
    » Response= 40-50% reduction
    » Recovery = score <7
    » Pros: gold standard, Cons: takes a long time to be administered, and has to be by someone trained.
  • Self-rated :
    » Beck Anxiety Inventory (BAI)
    » Zung Self-rated Anxiety Scale
  • Identify target symptoms for each type of anxiety disorders
  • Keep detailed diary to record fear levels, physical symptoms, cognitions and anxiety behaviors.
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9
Q

Treatment for GAD

A

Pharmacotherapy:

  • SSRI
  • Venlafaxine XR
  • Pregabalin

Non-pharmacological:
- CBT

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10
Q

Treatment for Panic Disorder

A

Pharmacotherapy:
- SSRI

Non-pharmacological:
- CBT

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11
Q

Treatment for Social Anxiety Disorder

A

Pharmacotherapy:
- SSRI

Non-pharmacological:
- Behavioural therapy

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12
Q

OCD

A

Pharmacotherapy:
- SSRI, clomipramine

Non-pharmacotherapy:

  • CBT
  • Exposure and prevention therapy
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13
Q

PTSD

A

Pharmacotherapy:
- SSRI

Non-pharmacotherapy:
- CBT, psychotherapy, counselling

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14
Q

Treatment principles of antidepressants

A
  1. All serotonergic antidepressants can be used for long-term management of anxiety disorders, OCD, PTSD
  2. Approach to dosing: titrate upwards
  3. Serotonergic antidepressant: effective for excessive worrying types of disorders. Onset at least 1-2 months, to see the full impact must wait for 3 months.
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15
Q

Different types of antidepressants (SSRI)

A

escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

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16
Q

Different types of antidepressants (SNRI)

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A

Venlafaxine XR, duloxetine

17
Q

Different types of antidepressants (TCA)

18
Q

Different types of anxiolytics (benzodiazepines)

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A

Alprazolam, clonazepam, diazepam, lorazepam

19
Q

Different types of anxiolytics (antihistamines)

20
Q

Different types of anxiolytics (beta blockers)

21
Q

Anticonvulsant

22
Q

Treatment: Adjunctives:

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A

A. Benzodiazepines
- Not recommended for monotherapy
- Therapeutic action: effective for physical symptoms of anxiety
» Fast onset of action: can be within 30 minutes
- Aim for short term treatment
- Gradual taper required
- High potency, therefore preferred for anxiety disorders
- E.g. Clonazepam, lorazepam, alprazolam XR (panic disorder)

B. Pregabalin (GAD

23
Q

Significant drug-drug interactions

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A
  • General:
    » Alcohol and other CNS depressants
    » Anticholinergic agents
    » MAOIs and SSRIs/TCAs combinations: serotonin syndrome
  • Antidepressant drug-drug interactions
  • Benzodiazepines DDI
    » CNS depressant effects with alcohol and other CNS depressants
    » Benzodiazepines + opioids = increased morality
24
Q

What are the long-term treatment goals of anxiety disorders?

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A
  • GAD, Panic disorder, SAD, PTSD
    » Remission of core anxiety symptoms, recovery of function
  • OCD :
    » Complete resolution of symptoms is often difficult to achieve
    » Relapse rates are very high with poor medication adherence
25
Recommended duration of all medication treatment
- At least 1 year for all anxiety disorders | - At least 1-2 year for OCD
26
What are some early and long-term adverse effects to pharmacotherapy?
- Early: >> Possible increased anxiety with antidepressants during first 1-2 weeks - Long-term: >> Sexual dysfunction and weight gain are common with antidepressants, may lead to discontinuation of treatment
27
escitalopram dose
10mg/day, 10-20mg/day max | PD, SAD: 5mg/day
28
fluoxetine dose
20mg/day, 80mg max | PD: 5mg
29
paroxetine dose
20mg/day | max: 40-60mg/day
30
sertraline dose
25mg/day, 200mg total
31
venlafaxine dose
37.5mg-75mg PD, PTSD: 37.5mg total: 75-225mg
32
clomipramine dose
25mg, 100-250mg total
33
Alprazolam dose
0. 5-4mg/day | max: 10mg
34
clonazepam dose
0. 5-1mg/day | max: 4mg/day
35
diazepam dose
4-15mg/day | max: 40mg / day
36
lorazepam
1-3mg/day | max: 8mg/day
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