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Anxiety Medications
Aka: Anxiety Medications, Anxiety Pharmacologic Management, Anxiety Management, Anxiolytic- See Also
- Anxiety Non-pharmacologic Management
- Anxiety Disorder
- Anxiety Secondary Cause
- Anxiety Symptoms
- Generalized Anxiety Disorder
- Obsessive Compulsive Disorder
- Body Dysmorphic Disorder
- Panic Disorder
- Social Anxiety Disorder (Social Phobia)
- Acute Stress Disorder
- Post-Traumatic Stress Disorder
- Excessive Worry
- Anxiety Non-pharmacologic Management
- Precautions
- Anxiety Non-pharmacologic Management is a cornerstone to Anxiety Management
- Medications should be adjunctive to non-medication therapy
- Benzodiazepines are best limited to short-term Anxiety Management
- Consider in severe anxiety while bridging to longterm strategies (e.g. SNRI and CBT)
- Longterm use risks dependency and abuse
- Anxiety Non-pharmacologic Management is a cornerstone to Anxiety Management
- Management: First-Line Agents
- Indicated as primary agents for anxiety as well as for concurrent depression
- Start at low dose and titrate to effective dose (warn patients of delayed effect over 2-4 weeks)
- Switch medications or add adjunctive agents if not effective after 4-6 weeks at optimal dose
- Continue medications for at least 12 months before tapering dose
- Serotonin-Norepinephrine Reuptake Inhibitors
- Venlafaxine (Effexor ER)
- Excellent first-line agent with good efficacy, and generally well tolerated in Anxiety Disorder
- Starting dose: 37.5 mg/day (of extended release)
- Duloxetine (Cymbalta)
- Has not been evaluated for use in Generalized Anxiety Disorder
- Venlafaxine (Effexor ER)
- Selective Serotonin Reuptake Inhibitors or SSRIs
- Indicated as primary agents for anxiety as well as for concurrent depression
- Management: Adjunctive - Benzodiazepines
- Precautions
- Use short-term for severe anxiety until SSRI or SNRI reaches effectiveness
- Consider longer-term only with caution and Consultation if severe anxiety refractory to non-Benzodiazepines
- Short-acting Benzodiazepines
- Lorazepam (Ativan)
- Indicated when a Benzodiazepine cannot be avoided in the elderly or with decreased Creatinine Clearance
- Avoid Alprazolam
- Higher risk of abuse and withdrawal (rapid onset, short half-life)
- Lorazepam (Ativan)
- Long Acting Benzodiazepines
- Clonazepam (Klonopin)
- Less abused than the shorter acting agents (but still, abuse is common)
- Clonazepam (Klonopin)
- Precautions
- Management: Adjunctive Pharmacotherapy - Second Line
- Buspirone (Buspar)
- Start at 7.5 mg orally twice daily (and may titrate to 30 mg twice daily)
- Use on scheduled basis (too long of delayed onset to be used as needed)
- More effective than Placebo in Generalized Anxiety Disorder
- Not effective in Panic Disorder
- Hydroxyzine (Atarax, Vistaril)
- Sedating Antihistamine with rapid onset that may be used as needed
- Atypical Antipsychotics
- Tricyclic Antidepressants (may be useful in transitioning off Benzodiazepines)
- Pregabalin (Lyrica)
- Relieves Anxiety Symptoms with similar efficacy to SSRIs and Benzodiazepines
- Minimum threshold effective dose is 200 mg per day
- Adverse effects include drowsiness, Dizziness and weight gain
- Risks for misuse and abuse (as with Gabapentin)
- Bech (2007) Pharmacopsychiatry 40(4): 163-8 [PubMed]
- Gabapentin (Neurontin)
- Has also been used instead of Pregabalin (Lyrica)
- Buspirone (Buspar)
- Management: Adjunctive Pharmacotherapy - Third Line
- MAO inhibitors
- Indicated for concurrent phobia
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Cardiovascular agents (excessive autonomic symptoms)
- Clonidine (Catapres)
- Beta Blockers
- Indicated for excessive autonomic symptoms
- Propranolol (Inderal)
- Atenolol (Tenormin)
- MAO inhibitors
- Management: Children
- Cognitive Behavioral Therapy (most important single intervention)
- Selective Serotonin Reuptake Inhibitors (SSRI)
- SSRIs combined with CBT are 80% effective in pediatric anxiety
- Fluoxetine (Prozac)
- Citalopram (Celexa)
- Sertraline (Zoloft)
- Avoid Paroxetine (Paxil) due to withdrawal risk
- Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
- Other agents with specific indications
- Clomipramine indications
- Inadequate effect with CBT and SSRI or SNRI
- Obsessive-Compulsive Disorder
- Benzodiazepine indications
- Short-term as needed use for severe anxiety and panic while initiating other therapy
- Clomipramine indications
- Precautions
- Avoid Tricyclic Antidepressants due to low efficacy in pediatric anxiety
- References
- (2013) Presc Lett 20(5): 29
- Todd (2012) Child Adolesc Psychiatr Clin N Am 21(4):789-806 [PubMed]
- Complications: Medications in the Elderly
- References
- (2014) Presc Lett 21(10): 60
- Greenberger (1995) Mind over Mood, Guilford Press
- Bourne (1997) Anxiety and Phobia Workbook, Fine Comm.
- Kavan (2009) Am Fam Physician 79(9): 785-91 [PubMed]
- Locke (2015) Am Fam Physician 91(9): 617-24 [PubMed]
- Wittchen (2002) J Clin Psychiatry 63:24-34 [PubMed]