Generalized Anxiety Disorder : Pharmacotherapy

1. GeneralizedAnxietyDisorder:Pharmacotherapy Flavio Guzman, MD

2. Overview

3. First-line agents for GAD Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

4. SSRIs for GAD How do we choose? Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

5. SSRIs for GAD How do we choose? Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

6. SSRIs for GAD Therapeutic dose MDD GAD Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

7. SSRIs for GAD Therapeutic dose MDD GAD Lower starting dose to prevent initial agitation Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

8. SSRIs for GAD Effective when there is comorbidity with MDD SSRI MDD GAD Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

9. SNRIs for GAD Duloxetine and Venlafaxine XR Efficacy SSRI SNRI Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

10. Other antidepressants: agomelatine • Agonist at M1 and M2 receptors • Antagonist at 5HT2C receptors • Approved in Canada, Latin America and Europe • Not FDA-approved • Two 12-week double blind RCT: more effective than placebo for GAD Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

11. Pregabalin Baldwin, David S., et al. "Pregabalin for the treatment of generalized anxiety disorder: an update." Neuropsychiatric disease and treatment 9 (2013): 883.

12. Pregabalin for GAD Baldwin, David S., et al. "Pregabalin for the treatment of generalized anxiety disorder: an update." Neuropsychiatric disease and treatment 9 (2013): 883.

13. Pregabalin - MOA Baldwin, David S., et al. "Pregabalin for the treatment of generalized anxiety disorder: an update." Neuropsychiatric disease and treatment 9 (2013): 883.

14. Pregabalin – Advantages and Disadvantages

15. Second-line agents

16. Second-line agents for GAD Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

17. Benzodiazepines for GAD Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

18. Benzodiazepines for GAD • Reduction of symptoms within minutes to hours Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

19. Benzodiazepines for GAD Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

20. Buspirone Bystritsky, A. Pharmacotherapy for Generalized Anxiety Disorder.In: UpToDate, Stein MB, UpToDate, Waltham, MA.(Accessed on October 1, 2014.)

21. Buspirone: mechanism of action

22. Buspirone: mechanism of action

23. Hydroxycine • Antihistamine • Efficacy superior to placebo • Clinical experience in the treatment of GAD remains limited Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

24. Quetiapine XR Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

25. Adjunctivetherapy • Second line: pregabalin • Third line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone • Notrecommended: ziprasidone Katzman, Martin A., et al. "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders." BMC psychiatry 14.Suppl 1 (2014): S1.

26. Treatment recommendations

27. Acute treatment • Consider an SSRI for first-line pharmacological treatment • SNRIs and pregabalin may be considered as alternative initial treatments if SSRIs are judged to be unsuitable • Remember that higher daily doses of pregabalin may be associated with greater response rates Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder."Journal of Psychopharmacology 28.5 (2014): 403-439.

28. Acute treatment Assess efficacy for up to 12 weeks 4 weeks No benefit: response unlikely Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder."Journal of Psychopharmacology 28.5 (2014): 403-439.

29. Longer term treatment Baldwin, David S., et al. "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder."Journal of Psychopharmacology 28.5 (2014): 403-439.