Medications for treatment of anxiety, panic, OCD, PTSD

FDA approved medications for generalized anxiety disorder (GAD)

escitalopram (Lexapro) paroxetine (Paxil) duloxetine (Cymbalta) venlafaxine (Effexor) alprazolam (Xanax) buspirone (Buspar) diazepam (Valium) lorazepam (Ativan)

How do benzodiazepines work?

facilitate the transmission of GABA (increase frequency that GABA channels open) induces relaxation, euphoria relaxes muscles, decreasing breathing

FDA approved medications for OCD

fluoxetine (Prozac) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft)

FDA approved medications for panic disorder

fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) venlafaxine (Effexor) alprazolam (Xanax) clonazepam (Klonopin)

tricyclic antidepressants (TCAs)

front-line pharmacological treatment for adults with major depression, anxiety disorders (GAD, panic disorder, and OCD), and pain syndromes

Venlafaxine XR

has been effective in treating adults with GAD at TDDs between 75-225 mg Children with anxiety disorders appear to respond to similar treatment

Monitoring of TCAs in pediatric patients

has the potential for cardiac risk Monitor vital signs, standing and sitting blood pressure, pulse, EKG repeat with dose adjustment with periodic monitoring

How do tricyclic antidepressants (TCAs) work for anxiety disorders?

known for mood-elevating effects inhibits both norepinephrine and serotonin

FDA approved medications for PTSD

paroxetine (Paxil) sertraline (Zoloft)

FDA approved medications for social anxiety disorder

paroxetine (Paxil) sertraline (Zoloft) venlafaxine (Effexor) fluvoxamine (Luvox)

fluoxetine in pediatric patients

results were the best when used for social phobia

Various drugs that have been reported as useful in individual cases of BDD

tricyclic drugs, MAOIs, pimozide and serotoninspecific drugs—for example, clomipramine and fluoxetine

other possible pharmacotherapy treatments for generalized anxiety disorder (GAD)

tricyclic drugs, antihistamines, βadrenergic antagonists

Most widely used benzodiazepine for panic

Alprazolam

Anxiety treatment medications NOT recommended in older adults

Antihistamines: anticholinergic effects can cause serious problems in older adults Second-generation antipsychotics

Guanfacine extended release (GXR)

FDA approved medication for ADHD in pediatric patients, ages 6-17 Evidence for use in pediatric anxiety is limited

Other anxiolytics: and what they're for

Gabapentin - anxiety (but some abuse) Hydroxyzine - PRN medication for anxiety Prazosin - PTSD nightmares Propanolol - performance anxiety Clonidine

What is recommended if patient does not respond to treatment for panic?

If fail to respond to one class of drugs, try another Try: Venlafaxine; combination of SSRI/tricyclic + benzodiazepine; or SSRI+ lithium Reassess the patient looking for comorbid conditions

How do SSRIs work for anxiety disorders?

Increase serotonin output by blocking the reuptake transporter presynaptically In addition to improving symptoms of depression, the increased serotonin also occurs in the amygdala and CSTC, improving symptoms of anxiety

What is important to know when using MAOIs to treat panic disorder?

Less likely to cause overstimulation than either SSRIs or tricyclic drugs Need for strict dietary restrictions

starting and target dose of paroxetine (Paxil) for PTSD

10-20mg/day; 20-50mg/day

starting and target dose of fluoxetine (Prozac) for OCD

20mg/day; 40-60mg

starting and target dose of paroxetine (Paxil) for OCD

20mg/day; 40-60mg

starting and target dose of sertraline (Zoloft) for PTSD

25-60mg/day; 50-200mg/day

starting and target dose of clomipramine (Anafranil) for OCD

25mg/day; 100-250mg

sertraline for young patients with GAD

50 mg/day may be an effective, safe dosage

starting and target dose of fluvoxamine (Luvox) for OCD

50mg/day; 200mg

starting and target dose of sertraline (Zoloft) for OCD

50mg/day; 200mg

Buspirone (Buspar)

5HT1A Partial Agonist (SPA) nonbenzodiazepine anxiolytic that has been shown to be effective in reducing anxiety symptoms without the side effects of benzodiazepines

How does Buspirone (BuSpar) work in anxiety disorders?

5HT1A Partial Agonist (SPA) for generalized anxiety Partial agonism pre- and post-synaptically, causing enhanced serotonergic activity in projections to amygdala, PFC, striatum, thalmus Delayed effectiveness indicates the therapeutic effects are downstream adaptive changes (receptors, etc) rather than acute action at the receptors

What is the typical duration of pharmacotherapy for panic disorder?

8-12 months

Monitoring of SSRIs in pediatric patients

Baseline weight, height, vital signs and monitor over time No laboratory tests are required for the use, but general baseline labs are helpful to establish health

Which medications have the most rapid onset of action against panic?

Benzodiazepines

What is important to know when using benzodiazepines to treat panic disorder?

Can be used while a serotonergic drug is being slowly titrated Have the potential for dependence, cognitive impairment, misuse Discontinuation produces a withdrawal syndrome; must be tapered slowly

What are the most effective Tricyclic and Tetracyclic Drugs for panic disorder?

Clomipramine and imipramine

What is important to know when using Tricyclic and Tetracyclic Drugs to treat panic disorder?

Must be titrated slowly upward to max doses to avoid overstimulation May not be achieved for 8-12 weeks More severe adverse effects than SSRIs

tricyclic antidepressants (TCAs) for pediatric patients

Overall, not enough evidence to support the frequent use as a monotherapy for children and adolescents with anxiety disorders, other than OCD

What is important to know when using SSRIs to treat panic disorder?

Patients may be sensitive to activating effects of this type of medication, particularly fluoxetine, so may need to start low and go slow

Monoamine Oxidase Inhibitors (MAOIs) used for panic

Phenelzine, tranylcypromine

First-line treatment for GAD

SSRI

First-line treatment for panic

SSRI

Paroxetine for panic disorder

SSRI; has sedative effects and tend to calm patients immediately, but weight gain is high

First line treatment for agoraphobia

SSRIs

First-line pharmacotherapy for social anxiety disorder

SSRIs

Pharmacological treatment for Trichotillomania (Hair-Pulling Disorder)

SSRIs Patients who respond poorly to SSRIs may improve with augmentation with pimozide, a dopamine receptor antagonist Other medications: fluvoxamine, citalopram, venlafaxine, naltrexone, lithium Case reports for buspirone, clonazepam, trazodone

First-line treatment for PTSD

SSRIs are considered first-line treatments due to efficacy, tolerability, safety reduce symptoms from all PTSD symptom clusters, not just symptoms similar to those of depression or other anxiety disorders

Most common pharmacotherapy treatments for generalized anxiety disorder (GAD)

SSRIs, benzodiazepines, buspirone, venlafaxine

Treatment options for panic disorder

Selective Serotonin Reuptake Inhibitors Tricyclic and Tetracyclic Drugs Benzodiazepines Monoamine Oxidase Inhibitors

Pharmacotherapy for agoraphobia

Selective Serotonin Reuptake Inhibitors Benzodiazepines Tricyclic and Tetracyclic Drugs

First-line pharmacological treatment for OCD

Standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if needed Serotonergic drugs provides response in 50-70%

Pharmacological treatment for Skin Picking Disorder

Support for the use of SSRIs (fluoxetine), opioid antagonist naltrexone (Revia), glutamatergic agents, lamotrigine (Lamictal)

How do SNRIs work for anxiety disorders?

Target both serotonergic and noradrenergic systems important regulatory role to the amygdala and CSTC circuits (thalmus); can reduce anxiety but may initially cause an increase in anxiety (increased noradrenergic activity before down regulation has occurred)

Monitoring of SNRIs in pediatric patients

Vital signs, weight, and height periodic laboratory assessment of lipids

Benzodiazepines belong to what class of medications?

anxiolytics

FDA approved medications for anxiety

buspirone (Buspar) chlordiazepoxide (Librium) clorazepate (Tranxene T-Tab) diazepam (Valium) doxepin (Silenor) hydroxyzine (Vistaril) lorazepam (Ativan) oxazepam (Serax) trifluoperazine (Stelazine)

cautions for benzodiazepines

can lead to dependency with chronic use (longer than 8 weeks)

What SSRIs are used off-label for OCD?

citalopram (Celexa) - initial dose 20mg, target dose 40-60mg escitalopram (Lexapro) - initial dose 10mg, target dose 20mg

FDA approvals for OCD in youth

clomipramine (10+); fluoxetine (7+); fluvoxamine (8+); sertraline (6+)

FDA approvals for GAD in youth

duloxetine (7+)

Some antidepressants and anxiolytics hold FDA approval for other disorders in youth are commonly seen being used for anxiety. What is one example of this?

escitalopram (12+ for depression)