Anxiety
Anxiety Medications
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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
Benzodiazepine
s 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
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
Selective Serotonin Reuptake Inhibitor
s or
SSRI
s
Paroxetine
(
Paxil
)
Escitalopram
(
Lexapro
) or
Citalopram
(
Celexa
)
Sertraline
(
Zoloft
)
Management
Adjunctive -
Benzodiazepine
s
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-
Benzodiazepine
s
Short-acting
Benzodiazepine
s
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)
Long Acting
Benzodiazepine
s
Clonazepam
(
Klonopin
)
Less abused than the shorter acting agents (but still, abuse is common)
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 Antipsychotic
s
Quetiapine
(
Seroquel
)
Tricyclic Antidepressant
s (may be useful in transitioning off
Benzodiazepine
s)
Imipramine
(
Tofranil
)
Desipramine
(
Norpramin
)
Pregabalin
(
Lyrica
)
Relieves
Anxiety Symptoms
with similar efficacy to
SSRI
s and
Benzodiazepine
s
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
)
Management
Adjunctive Pharmacotherapy - Third Line
MAO inhibitor
s
Indicated for concurrent phobia
Phenelzine
(
Nardil
)
Tranylcypromine
(
Parnate
)
Cardiovascular agents (excessive autonomic symptoms)
Clonidine
(
Catapres
)
Beta Blocker
s
Indicated for excessive autonomic symptoms
Propranolol
(
Inderal
)
Atenolol
(Tenormin)
Management
Children
Cognitive Behavioral Therapy
(most important single intervention)
Selective Serotonin Reuptake Inhibitor
s (
SSRI
)
SSRI
s 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
)
Venlafaxine
(
Effexor
)
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
Precautions
Avoid
Tricyclic Antidepressant
s 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
Ataxia
with risk of falls and secondary
Fracture
Decreased cognition
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]
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