Anxiety Kendra Saxvik Pharm D BCPP Clinical Pharmacy

Anxiety Kendra Saxvik, Pharm. D, BCPP Clinical Pharmacy Specialist, Mental Health

Anxiety Disorders �Generalized Anxiety Disorder �Specific Phobias �Social Anxiety Disorder �Panic Disorder �Unspecified Anxiety Disorder �Obsessive Compulsive Disorder �Note this is separate section in DSM 5

Medication Basics �Maintenance medications preferred for GAD and other pervasive anxiety disorders �PRN medications do not treat underlying anxiety disorder, though do help symptoms �For specific phobias, or limited social phobias (i. e. presentations) often only need PRN medication �Panic disorder and OCD require high doses �Many agents also treat depression �Bonus, because depression and anxiety go hand in hand

Maintenance Medications

SSRI’s �Selective Serotonin Reuptake Inhibitors �Mechanism: inhibit serotonin uptake in CNS, resulting in more available serotonin �What that means �More serotonin = more signaling between neurons �Described as feeling less restless, less triggering of physical symptoms � Both in frequency and intensity �“Better able to relax” �Less “my brain won’t shut off”

SSRI’s �Many side effects resolve within a week �Common side effects: �Upset stomach �Sexual dysfunction �Serious side effects �Suicide Risk: Black Box Warning under 24 years old �Serotonin syndrome (fever, stiffness, agitation, tremor) �Time to Effect � 6 -8 weeks at a therapeutic dose

SSRI’s Generic Brand Dosing Range Citalopram Celexa 10 -40 mg daily Escitalopram Lexapro 5 -20 mg daily Fluoxetine Prozac 10 -80 mg daily Paroxetine Paxil 10 -60 mg daily Sertraline Zoloft 25 -200 mg daily

SNRI’s �Serotonin Norepinephrine Reuptake Inhibitors �Mechanism: inhibits reuptake of serotonin and norepinephrine in the CNS �What that means: similar to SSRI’s �More serotonin and norepinephrine is primary difference �May also work for nerve pain/fibromyalgia

SNRI’s �Many side effects resolve within a week �Common side effects: �Increased blood pressure �Upset stomach �Sexual dysfunction �Serious side effects �Suicide Risk: Black Box Warning under 24 years old �Serotonin syndrome (fever, stiffness, agitation, tremor) �Time to Effect � 6 -8 weeks at a therapeutic dose

SNRI’s Generic Brand Dosing Range Desvenlafaxine Pristiq 50 mg daily Duloxetine Cymbalta 20 -120 mg daily Venlafaxine Effexor 37. 5 mg – 300 mg

As Needed (PRN) Medications

Benzodiazepines �Mechanism: Bind to GABA receptor, increasing the receptors activity and inhibiting CNS reactivity �What that means �Decreased firing of the neurons �“More relaxed, more calm” �Only works as long as drug is at a therapeutic level in the system �“Alcohol in a pill” �Time to effect: 15 -60 minutes �Note: Effect only lasts 2 -12 hours

Benzodiazepines �Common Side Effects �Disinhibition �Dizziness, unsteadiness �Depression �Sedation �Cognitive effects �Falls �Rebound anxiety �Serious Side Effects �Physical dependence and abuse �Severe withdrawal (tremor, anxiety, seizures, death) �Risk in overdose: can be fatal in combination �Drug Interactions

Benzodiazepines Generic Brand Equivalent Dose Dosing Range Alprazolam Xanax 1 mg 0. 25 – 1 mg QID (4 times daily) Clonazepam Klonopin 0. 5 mg 0. 25 – 2 mg BID (2 times daily) Diazepam Valium 10 mg 2 -10 mg BID-QID (2 -4 times daily) Lorazepam Ativan 1 mg 0. 5 – 2 mg TID (3 times daily)

Other Medications �Buspirone �Common side effects � Dizziness � Nausea �Time to Effect: weeks, though some benefit with each dose �Hydroxyzine �Helps relax before sleep �Common side effects � Sedation � Dry mouth �Time to Effect: 30 -60 min

Other Medications Generic Brand Dosing Range Buspirone Buspar 7. 5 mg – 30 mg BID-TID (2 -3 times daily) Max: 60 mg daily Hydroxyzine Atarax Vistaril 10 -100 mg BID-QID (2 -4 times daily)

Talking to Prescribers

General Recommendations �Be concise �Be confident �Be courteous �Have plan or recommendations

SBAR Communications �Situation �Background �Assessment �Recommendation

SBAR Example S This is Kendra, calling from Texas A&M, about our mutual patient Anita Relax. I am calling because she says that she is feeling increasingly anxious and that her medication is not working. B Ms. Relax has been taking her Xanax up to four times a day. This medication previously worked, and she has been on it for some time. She also has been working with me on therapy for handling her anxiety. A Based on this, I am concerned that she needs a medication change to better address her anxiety. R I recommend having her a) Come in for an earlier appointment to discuss with you, to discuss a change to maintenance medication as her anxiety is no longer every once in a while. b) Referred to a psychiatric specialist as I believe she may need more intensive medication regimen