Anxiety

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Definition
When a person has an anxiety disorder, the symptoms are chronic and severe and
cause great distress. The disorder can interfere with the ability to do well at school
or work, and can harm relationships.

Symptoms
Occasional anxiety (fear, worry) and any physical symptoms (tachycardia,
palpitations, shortness of breath, stomach upset, chest pain or other pain, insomnia
or fatigue)

Drug-Disease interaction

Albuterol (if used too frequently or incorrectly)

Antipsychotics (e.g., aripiprazole, haloperidol)

Bupropion

Caffeine, in high doses

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 Decongestants (e.g., pseudoephedrine)

Illicit drugs (e.g., cocaine, LSD, methamphetamine)

Levothyroxine

Steroids

Stimulants (e.g., amphetamine, methylphenidate)

Theophylline

Other Anxiety Disorder

Major types of anxiety disorders are generalized anxiety disorder (GAD)
panic disorder (PD)
Social anxiety disorder (SAD)
Other disorders that have symptoms of anxiety include:
Obsessive compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD).

Non-Drug Treatment

Lifestyle changes can improve symptoms.

Increasing physical activity, helping others, community involvement, yoga and

meditation, are some of the methods that can broaden the patient's outlook and
reduce stress.

Cognitive Behavioral Therapy (CBT) is a type of mental health treatment it

provides adequate relief without the need for chronic medications.

Natural Products

Passionflower appears to be safe and is rated as “possibly effective”

Kava is used as a relaxant, but it can damage the liver and should not be
recommended

St. Johns wort, used for depression and anxiety, is a strong CYP3A4 inducer
and causes photosensitivity and is serotonergic.

Valerian is used for anxiety and sleep

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 Drug Treatment
The selection of a drug is based on both the efficacy and the risk of adverse effects.

Benzodiazepines (BZDs) should only be used short-term.

First-Line
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin norepinephrine reuptake inhibitors (SNRIs)

🧠 Escitalopram - Fluoxetine - Paroxetine - Sertraline - Duloxetine -

Venlafaxine

🧠 Note: Typically start at half the initial dose used for depression and slowly
titrate to minimize anxiousness and jitteriness (common during the first
couple of weeks)
Do not provide immediate relief; takes at least four weeks or more at
doses in the higher end of the dosing range for a noticeable effect

Second-Line
Buspirone

🧠 MOA: The mechanism of action of buspirone is unknown, but its effects

may be due to its affinity for 5-HT1A and 5-HT2 receptors. It does not
affect GABA, an inhibitory neurotransmitter.

🧠 Combination: Considered to be a more favorable add-on agent than

benzodiazepines in elderly patients (less sedating) or if there is a risk for
benzodiazepine abuse.
Does not provide immediate relief; takes 2-4 weeks to work when taken
on a scheduled basis

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 🧠 CI: Do not use with MAO inhibitors or within 14 days of discontinuation.
Avoid use in severe kidney or liver impairment

🧠 SE: Nausea, dizziness, drowsiness, headache, lightheadedness,

excitement

🧠 Note: No potential for abuse Alone, tolerance or physiological

dependence.
When switching from a benzodiazepine to buspirone, the benzodiazepine
must be tapered off slowly

Tricyclic Antidepressants

🧠 Amitriptyline - Imipramine - Nortriptyline

🧠 Note: Not FDA-approved for anxiety.

Risk of adverse effects (e.g., anticholinergic side effects) limit use.

Hydroxyzine

🧠 MOA: Sedating antihistamine with anticholinergic activity

🧠 CI:Should not be used long-term; should be used short-term, as needed,

as an alternative to benzodiazepines

Pregabalin/Gabapentin

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 🧠 MOA:Not FDA-approved for anxiety but has shown benefit in patients
with anxiety and neuropathic pain

🧠 Note:Has immediate anxiolytic effects similar to benzodiazepines

Special Situations
Propranolol

🧠 MOA: Beta blocker

🧠 SE: Can cause CNS (e.g., dizziness, confusion)

🧠 Note: Not FDA-approved for anxiety but can reduce symptoms of stage
fright or performance anxiety (e.g., tremor, tachycardia)
Give 10-40 mg one hour prior to an event (such as a public speech)

Benzodiazepines (BZDs)

🧠 Lorazepam - Oxazepam - Temazepam - Alprazolam - Clonazepam -

Diazepam

🧠 MOA: BZDs enhance GABA, an inhibitory neurotransmitte,do not treat

the underlying causes of anxiety, use for short-term becuse it can cause
dependence.

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 🧠 CI: Acute narrow-angle glaucoma, sleep apnea, severe respiratory
insufficiency, severe liver disease.
Pregnancy - crosses the placenta; can cause birth defects and neonatal
withdrawal syndrome

🧠 SE: Somnolence, dizziness, ataxia, weakness, lightheadedness

🧠 Antidote: Flumazenil

🧠 Note : - BZDs are not preferred for anxiety or for sleep.

- (Lorazepam, Oxazepam, Temazepam) are safer with elderly patients
and liver impairment.
- Induce Sleep : lorazepam or temazepam

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