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)
