Pharmacotherapy of Anxiety Disorders (GAD, Panic, & SAD) Declaration of Interests
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1 Pharmacotherapy of Anxiety Disorders (GAD, Panic, & SAD) University of Texas Health Science Center San Antonio Pharmacotherapy Education and Research Center (PERC) 7703 Floyd Curl Drive - MSC 6220 San Antonio, TX Saklad@uthscsa.edu Stephen R Saklad, Pharm.D., BCPP Clinical Associate Professor The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division Adjoint Associate Professor University of Texas Health Science Center San Antonio School of Medicine, Pharmacotherapy Education and Research Center Director, Psychiatric Pharmacy Program in San Antonio Clinical Pharmacologist, San Antonio State Hospital This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. To view a copy of this license, visit or send a letter to Creative Commons, 171 Second Street, Suite 300, San Francisco, California, 94105, USA. Employed Clinical Associate Professor College of Pharmacy The University of Texas at Austin Appointed Clinical Pharmacologist San Antonio State Hospital Texas Department of State Health Services Adjoint Associate Professor Pharmacotherapy Education and Research Center, School of Medicine UT Health Science Center San Antonio Declaration of Interests Speakers Bureau or Consultant Actavis Jazz Otsuka Sunovion Several professional organizations College of Psychiatric and Neurologic Pharmacists Foundation Board of Directors College of Psychiatric and Neurologic Pharmacists Business Development Council Expert witness on both defendant and plaintiff sides Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 1 of 11
2 Objectives Clinical Presentation of Generalized Anxiety Disorder Psychological Anxiety Worries Keyed Up On Edge Physical Restlessness Fatigue / Sleep Muscle Tension Irritability Cognitive Concentration Blank Mind Function Social Family Work Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 2 of 11
3 Metabolic Endocrine Medical Causes of Anxiety Symptoms Need to be Ruled Out Cardiovascular Neurologic Anxiety Symptoms Respiratory Cancer Anemia SLE Medications Can Cause Anxiety Symptoms Anticonvulsants Antidepressants Antihypertensives Antibiotics Bronchodialators Caffeine Corticosteroids Dopamine! Herbals Illicit Norepinephrine! Nicotine NSAIDS Thyroid Toxicity Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 3 of 11
4 Pharmacotherapy Overview of Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Social Anxiety Disorder Drugs of Choice 2nd Tier Alternatives Duloxetine Escitalopram Paroxetine Sertraline Venlafaxine XR SSRIs Venlafaxine XR Escitalopram Fluvoxamine Paroxetine Sertraline VenlafaxineXR Benzodiazepines Buspirone Imipramine Alprazolam Citalopram Clomipramine Clonazepam Imipramine Clonazepam Citalopram Hydroxyzine Pregabalin Quetiapine Phenelzine Clonazepam Gabapentin Mirtazapine Phenelzine Pregabalin Antidepressants are DOC Generalized Anxiety Disorder Long-term Goal is Remission Antidepressant Onset is 2 4 Weeks Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 4 of 11
5 Adverse Events Need to be Minimal Compared to Benefits Metabolic Weight, Glucose, Lipids Cardiac Orthostasis, Hypertension, QTc Central Nervous System Dizziness, Anticholinergic, Sedation, Insomnia Autonomic" Nervous System Anticholinergic, Sweating, Tremor Gastrointestinal NVD Urogenital ED, Priapism, Anorgasmia Generic Non-Benzodiazepines for GAD Common Brand Name (All Generic Except as Noted) Dosage Range Duloxetine Cymbalta Escitalopram Lexapro Imipramine Tofranil Paroxetine Paxil, Pexeva Sertraline Zoloft Venlafaxine XR Effexor XR Buspirone BuSpar Hydroxyzine Vistaril, Atarax Pregabalin Lyrica (generic 2018) Quetiapine Seroquel (IR now; XR 2017) Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 5 of 11
6 Generic Alprazolam Benzodiazepines for GAD Common Brand Name (Generics Available) Dosage Range Xanax, Niravam (ODT) Xanax XR 1 10 Equivalent Dose Chlordiazepoxide Librium Clonazepam Klonopin, Klonopin Wafers (ODT) Clorazepate Tranxene, Tranxene SD Diazepam Valium Lorazepam Ativan Oxazepam Serax Pharmacokinetics of the Benzodiazepines Generic Tmax (hr) t½ Metabolism Alprazolam Oxidation Chlordiazepoxide N-Dealkylation, Oxidation Clonazepam Nitroreduction Clorazepate Oxidation Diazepam Oxidation Lorazepam Glucuronidation Oxazepam Glucuronidation Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 6 of 11
7 Algorithm for Treatment of Generalized Anxiety Disorder (See End of Handout) Antidepressants are DOC Panic Disorder Antidepressant Onset is 8 12 Weeks Long-term Goal is Remission Clonazepam or Alprazolam ER for Breakthrough Panic Sx Rx Duration Unknown Treat Months, then Taper 4 6 Months Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 7 of 11
8 Psychological Depersonalization Derealization Fear of Losing Control Going Crazy Dying Clinical Presentation of Panic Disorder Physical Abdominal Distress Chest Pain Chills Dizziness Feeling of Choking Hot Flushes Nausea Paresthesias Palpitations Shortness of Breath Sweating Tachycardia Tremor Pharmacotherapy of Panic Disorder Generic Common Brand Name Starting Dose Dosage Range Citalopram Celexa Escitalopram Lexapro Fluoxetine Prozac Fluvoxamine Luvox Paroxetine Paxil, Pexeva Paxil CR Sertraline Zoloft Venlafaxine XR Effexor XR Alprazolam Xanax 0.75 (0.25 TID) 4 10 Xanax XR Clonazepam Klonopin 0.25 Daily or 0.25 BID 1 4 Diazepam Valium 6 15 (2 5 TID) 5 20 Lorazepam Ativan (0.5 1 TID) 2 8 Imipramine Tofranil Phenelzine Nardil Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 8 of 11
9 Social Anxiety Disorder (SAD) SSRIs or Venlafaxine are DOC Antidepressant Onset is 8 12 Weeks Long-term Goal is Remission After Improvement: >1 Year Maintenance Rx Clinical Presentation of Social Anxiety Disorder Fear of Being Scrutinized Embarrassed Humiliated Fear of Situation" (1, 2 or Generalized) Eating Writing Authority Figures Public Speaking Talking to Strangers Public Toilets Physical Sx Blushing Butterflies Diarrhea Sweating Tachycardia Trembling Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 9 of 11
10 Pharmacotherapy of SAD Generic Common Brand Name Starting Dose Dosage Range Citalopram Celexa * Escitalopram Lexapro Fluvoxamine CR Luvox CR Paroxetine Paxil, * Paxil CR * Sertraline Zoloft * Venlafaxine XR Effexor XR * Phenelzine Nardil Buspirone BuSpar * 20 (10 BID) Clonazepam Klonopin * Gabapentin Neurontin * 300 (100 TID) 900 3,600 Mirtazapine Remeron * Pregabalin Lyrica 300 (100 TID) 600 Quetiapine Seroquel * Social Anxiety Disorder Treatment Should Improve Three Areas Anxiety Symptoms Functioning Improvement Feeling of Well-being Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP <Saklad@uthscsa.edu> Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request. Page 10 of 11
11 Copyright 2015 Stephen R. Saklad, Pharm.D., BCPP Licensed under CC 3.0 BY-NC-ND Unported. Additional Rights by Request.Page 11 of 11
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