Generalized anxiety disorder
Respont to the two post below with 1 page 3 citations / references ( each post neeed an independent response ) = 2 responses and 6 citations ( each response 3 )
Post 1
Generalized anxiety disorder “a chronic condition characterized by uncontrollable worrying.” (Rosenthal & Burchum pg. 243) Treatment of GAD includes nonpharmacological therapies to go hand in hand with drug interventions. Serotonergic reuptake inhibitors are considered first-line therapy when treatment is selected followed by benzodiazepines as second-line therapy.
SSRIs “are metabolized by the liver by cytochrome P-450 mixed function oxidase microsomal enzymes.” (Cushing, 2021) Typically, SSRIs have a half-life of roughly 20-24 hours, there are variations to that number with a peak of concentration in 2-10 hours. Unlike benzodiazepines, SSRIs have a delayed onset with initial response seen in the first week after starting treatment with optimal results several weeks after start of therapy. SSRIs “block reabsorption of serotonin into the neurons.” (Mayo Clinic, 2019) This allows for more serotonin to be available for transmission of messages between neurons. SNRIs are primarily metabolized through the liver with the half-life ranging from 8-12 hours for the different medications under the SNRI category. Like SSRIs, SNRIs have a delayed onset therefore reassessing the first week of therapy and then again, several weeks later when optimal response is present. SNRIs “block the reabsorption of the neurotransmitters serotonin and norepinephrine in the brain.” (Mayo Clinic, 2019)
Buspirone is another drug that can be used in the management/treatment of generalized anxiety. As with SSRIs and SNRIs, buspirone has a delayed therapeutic effect, therefore not suitable for as needed use. Unlike benzodiazepines, this medication does not influence the CNS and reduces the risk of abuse while utilizing medication for treatment. Buspirone is approved for short-term treatment of anxiety. “The mechanism by which it relieves anxiety has not been established.” (Rosenthal & Burchum pg. 244) Benzodiazepines are the first choice for acute anxiety because of their quick effect, but because of the high risk for abuse patients should be cautioned.
Due to its high risk of relapse use of medications such as SRIs would prove beneficial as buspirone, and benzos are meant to be used for short-term treatment. Just like with several medications there are side effects/adverse reactions to monitor for but with the right education the patient will be familiar with what to monitor for and what to report.
Cushing, T. A. (2021, July 19). Selective serotonin reuptake inhibitor toxicity. Background, Etiology, Epidemiology. Retrieved January 20, 2022, from https://emedicine.medscape.com/article/821737-overview#a3
Sansone, R. A., & Sansone, L. A. (2014, March). Serotonin norepinephrine reuptake inhibitors: A pharmacological comparison. Innovations in clinical neuroscience. Retrieved January 20, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008300/
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Mayo Clinic Staff. (2019, September 17). Selective serotonin reuptake inhibitors (SSRIs). Mayo Clinic. Retrieved January 20, 2022, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825#:~:text=SSRIs%20block%20the%20reabsorption%20(reuptake,affect%20serotonin%2C%20not%20other%20neurotransmitters.
Mayo Clinic Staff. (2019, October 5). Serotonin and norepinephrine reuptake inhibitors (SNRIs). Mayo Clinic. Retrieved January 20, 2022, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20044970#:~:text=Serotonin%20and%20norepinephrine%20reuptake%20inhibitors%20(SNRIs)%20are%20a%20class%20of,)%20pain%2C%20especially%20nerve%20pain.
Post 2
Generalized anxiety disorder (GAD) is excessive worrying about several events that lasts longer than 6 months (Rosenthal & Burchum, 2021). Symptoms include vigilance, tension, apprehension, poor concentration, difficulty falling or staying asleep, trembling, muscle tension, restlessness, palpitations, tachycardia, and sweating (Rosenthal & Burchum, 2021). Patients with GAD typically have an accompanying psychiatric disorder such as depression. Additionally, compared to the other anxiety disorders, GAD is least likely to be cured.
Treatment Options
GAD treatment is dependent on the severity of the symptoms and falls into two categories nondrug and drug therapy (Rosenthal & Burchum, 2021). Nondrug treatment includes relaxation therapy, biofeedback, cognitive behavioral therapy, and supportive therapy. Drug options include serotonergic reuptake inhibitors (SRI’s), nonbenzodiazepine-nonbarbiturate, and benzodiazepine. First line drug therapy is the SRIs including selective serotonin uptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), and buspirone. Onset is delayed with these medications, but they are better for long term use. Second choice is the benzodiazepines. One major benefit of Benzodiazepines is the rapid onset of relief of symptoms. However, they have a huge potential for abuse, and should not be used long term (Rosenthal & Burchum, 2021).
Case Study
The patient is a 46 y.o. white male employed as a welder at a steel factory (Laureate Education, 2019). He was in the ER because he thought he was having a heart attack, symptoms included chest tightness, shortness of breath, and feeling of impending doom. He has history of hypertension, that is treated with a low sodium diet, he is overweight, other medical history is unremarkable. Myocardial infarction was ruled out, physical exam was WNL. Patient reports continued “anxiety attacks” of chest tightness and shortness of breath. He reports ETOH use of 3-4 beers/night. He was diagnosed with GAD. The treatment options include starting the patient on Zoloft 50 mg PO daily, Burpirone 10 PO BID, or Imipramine 25 mg BID.
Based on the patient presented in the case study, I elected to begin treatment with Burspirone 10 BID, because it is considered first line treatment for GAD, and the other options are not, even though Zoloft is an SSRI, it is not under the recommended treatment plan (Rosenthal & Burchum, 2021).
Upon return to the clinic the patient reported a slight decrease in symptoms, but he still feels very anxious. His HAMA score decreased from 26 to 23. My options were to then increase Buspirone to 10 mg TID, Buspirone 20 mg TID or discontinue Buspirone and start Lexapro 10 mg PO daily. I elected to increase Buspirone to 10 mg TID.
At his next check up in four weeks, the patient reports no change in anxiety. I elected to discontinue buspirone and begin Zoloft 50 mg orally daily. In this scenario, buspirone meets criteria for treatment failure, so it is appropriate to discontinue it and begin another first line option (Laureate Education, 2019). Sertaline is a SSRI that has been shown to reduce anxiety symptoms and may prove an effective treatment for GAD (Brawman-Mintzer et al., 2006).
Pharmacokinetics and Pharmacodynamics
I do not think pharmacokinetics or pharmacodynamics would have a large impact on this patient, primarily because he is younger, and not taking any other medications. The main problem I could foresee is due to the patients history of ETOH use and the use of a benzodiazepine. This is due to the potential to abuse benzodiazepines, and it should be used cautiously in patients that abuse ETOH (Rosenthal & Burchum, 2021). Additionally, if the patient does need medication for his hypertension there could potentially be an interaction depending on the medication chosen.
References
Brawman-Mintzer, O., Knapp, R. G., Rynn, M., Carter, R. E., & Rickels, K. (2006). Sertraline treatment for generalized anxiety disorder: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry, 67(6):874-81. doi: 10.4088/jcp.v67n0603.
Laureate Education (Producer). (2019). Generalized anxiety disorder [Interactive media file]. Baltimore, MD: Author.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
