#14 Anxiety mgmt .txt

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#14 Anxiety mgmt .txt
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2012-07-25 11:58:09
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  1. #14 Anxiety Management
  2. First line treatment for panic disorder, GAD, social anxiety disorder, PTSD and OCD?
    SSRIs and SNRIs
  3. 2nd line treatments for anxiety disorders
    • TCAs
    • Novel action anti-depressants (Buproprion and Mirtazepine)
    • RIMA/MAOIs
  4. Based on Can Anxiety Disorder Treatment Guidelines 2006 - which are indicated for PD (panic disorder)?
    • SSRI:
    • Citalopram (Celexa) - usual dose 20-40mg qD
    • Escitalopram (Cipralex) - 5-40 mg qD
    • Fluoxetine (Prozac) - 5-60 mg qD
    • Fluvoxamine (Luvox) 50-250mg qD
    • Paroxetine (Paxil) 10-50mg qD
    • Sertraline (Zoloft) 50-200mg qD
  5. SNRI:
    Venlafaxine XR (Effexor) - 37.5mg - 225mg qD
  6. *cautions - initial agitation, worsening of panic attacks, increased suicidal ideation in young (< 25 yrs), weight gain, sexual dysfxn
  7. 2nd line for PD?
    • TCAs - very effective but worse side effects
    • cardiac toxicity, overdose effects, seizure risk at higher doses
    • Imipramine, Clomipramine
  8. Which are 1st line indicated drugs for GAD?
    • SSRI:
    • Escitalopram (Cipralex) 5-40mg/d
    • Paroxetine (Paxil) 10-50mg/d
    • Sertraline (Zoloft) 50-200mg/d
    • SNRI:
    • Duloxetine (Cymbalta) 60-120 mg/d
    • Venlafaxine XR (Effexor) 37.5 - 225 mg/d
  9. Indicated drugs for OCD?
    • 1st line:
    • SSRI's (no SRNI's)
    • Escitalopram (Cipralex) 5-40 mg/d
    • Fluoxetine (Prozac) 5-60 mg/d
    • Fluvoxamine (Luvox) 50-250 mg/d
    • Paroxetine (Paxil) 10-50 mg/d
    • Sertraline (Zoloft) 50-200 mg/d
  10. 2nd line: TCAs - Clomipramine 25-150 mg/d
    3rd line: RIMA/MAOI - Tranylcypromine (Parnate) 20-60mg/d
  11. Indicated drugs for PTSD?
    • Fluoxetine (Prozac) 5-60mg/d
    • Paroxetine (Paxil) 10-50mg/d
    • Sertraline (Zoloft) 50-200mg/d
    • Venlafaxine XR (Effexor) 37.5-225 mg/d
  12. Indicated drugs for SAD?
    • Luvox 50-250 mg/d
    • Paxil 10-50mg/d
    • Zoloft 50-200mg/d
    • 2nd line: Moclobemide (Manerix) 300-900mg/d (a RIMA/MAOI)
  13. General principles of pharmacologic management
    • -specific phobias rarely need meeds
    • -SSRI and SNRI are effective for PD, SAD, OCD, PTSD and GAD
    • -Paxil and Zoloft are effective for all 5 disorders, others vary
    • - All antidepressants should start very low dose - b/c extremely intolerant of agitation and akathisia.
    • -Use lowest dose possible at first, but usually need same or higher dose than for depression
    • -start low and go slow vs. challenge pts with dose they can't tolerate
  14. How to try with antidepressant?
    • If 1st SSRI/SNRI doesn't help at all after 8 weeks - discontinue slowly and substitute another.
    • If 2nd doesn't help - consult psychiatry
    • OCD - switch to clomipramine with usual precautions
    • Length of treatment for anxiety disorders is at least 12 months, then slow taper
    • - relapse during withdrawal is less if given CBT
  15. Use of anxiolytics in anxiety disorders
    • Effective for most
    • Not for OCD
    • Caution in PTSD b/c high rates of comorbid substance abuse
    • Maximum 6-8 weeks in a new case is the suggested limit
    • Buspirone helps in GAD to augment antidepressant
  16. How to augment SSRI/SNRI in OCD?
    • Add haloperidol or rispiridone in low dosage
    • 0.5mg qD or BID (especially if tics)
  17. Augmentation strategies in other anxiety disorders?
    • -Atypical antipsychotics can be added to antidepressant
    • Not for monotherapy
    • - Treat 2nd comorbid disorder (if stimulant for ADHD, anticonvulsant for BAD)
  18. Pyschotherapy
    • CBT is best, 1st line therapy for anxiety
    • Patient choice is important factor in effect
    • Pt who choose to do it do better
    • Overall CBT is as effective as medication
    • no evidence of combination being better than either one alone
    • Ideally 2x/wk for 60-90 min for 12-20 sessions
  19. What is reasonable to expect of a primary care clinician for anxiety?
    • Follow up on complaints of anxiety
    • Clarigy major anxiety Sx
    • Discuss probably Dx
    • Offer psychoeducation about self-help, psychotherapy, medication use
    • Refer for community-based self-help
    • Offer medication treatment:
    • SSRI or SNRI +/- BZD
    • second SSRI or SNRI
    • specific augmentation
  20. When to refer to specialist?
    • Following attempt to treat patient or earlier if patient is significantly impaired
    • Chidren/Teens too fearful to attend school or socialize
    • Adults cannot go to work or maintain fxn
    • multiple comorbid mental disorders (depression, substance abuse, suicidality)
  21. OSCE STATION ON ANXIETY - part 1 history
    • Hx:
    • ID
    • CC
    • HPI
    • exact anxiety Sx - onset, triggers, etc
    • impaired fxn
    • stressors
    • coping/supports
    • substances, caffeine
    • abuse
    • Screen for other anxiety disorders
    • Screen for suicidally, depression, mania, psychosis
    • Past psych - meds, dx, psychiatrist visits, hospitalizations, suicide attempts
    • PMHx - head injury, thyroid problems, anemia, etc.
    • Meds
    • FHx
  22. OSCE STATION part 2 physical and labs
    • OE: vitals, CVS, neurologic (tremor), thyroid, abdo for masses
    • Order labs - CBC, lytes, Cr, LFTs, FBG, F lipids, TSH
    • U/A, urine drug screen, 24h CrCl (Hx of renal dz)
    • ECG (> 40 yrs)
  23. OSCE STATION part 3 - mgmt
    • psychoeducation of probable Dx
    • Self help strategies
    • Avoid caffeine and alcohol
    • Exercise!
    • Box breathing, progressive relax'n exercises
    • CBT referral PRN
    • SSRI/SNRI +/- BZD
    • F/U in 2 weeks
  24. Self help and self-management resources to tell Pt:
    • www.cmha.ca Can Mental Health Association
    • www.anxietycanada.ca
    • www.anxietytreatment.ca
    • Antidepressant Skills Workbook
    • www.comh.ca/selfcare/
    • Box breathing
    • Progressive relaxation
    • Exercise

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