Antipsychotics Antipsychotic medications can be divided into two general groups: ● First-generation antipsychotics, also called typical antipsychotics, function as dopamine receptor antagonists. ● Second-generation antipsychotics, also called atypical antipsychotics, are serotonin and dopamine antagonists. Antipsychotics are FDA-approved to treat and manage symptoms of numerous psychiatric conditions, including schizophrenia, bipolar disorder, and acute mania. They also have a variety of off-label uses, including managing symptoms of anxiety and GAD. Evidence in support of their use for GAD and anxiety symptoms is inconclusive, and antipsychotics are not used first-line for treating anxiety disorders. Trifluoperazine and other first-generation antipsychotics are associated with adverse reactions including weight gain, sedation, and extrapyramidal side effects (EPS), such as bradykinesia, tremor, rigidity, and tardive dyskinesia. Trifluroperazine is currently the only antipsychotic with an FDA indication for treating anxiety; it’s approved for short-term treatment of anxiety not related to psychosis. It’s recommended to avoid using trifluoroperazine as an anxiolytic for longer than 12 weeks, due to the risk for possibly irreversible tardive dyskinesia (Ameer & Saadabadi, 2021). Second-generation antipsychotics, including olanzapine (Zyprexa) and quetiapine (Seroquel), still carry risk for weight gain, in addition to metabolic syndrome, type 2 diabetes, and Antihistamines Hydroxyzine (Vistaril) is a histamine-1 receptor (H1) blocker and may be used as an alternative to benzodiazepines in both inpatient and outpatient settings to manage anxiety and panic attacks. It’s the only antihistamine with FDA approval for use in anxiety. It’s also used off-label for treating GAD, PD, SAD (Garakani et al., 2020). The therapeutic dose range is 25-100 mg/day. Perhaps the biggest drawback to hydroxyzine as a pharmacologic treatment for anxiety is the tendency for patients
sedation, but with less risk for EPS, particularly tardive dyskinesia (Ameer & Saadabadi, 2021). Several reviews have shown quetiapine to have utility as monotherapy for treating GAD, but it was also found to be less tolerable by patients compared to other anxiolytic treatments (Garakani et al., 2020). Risperidone and aripiprazole may have an adjunctive role for treating SAD (Garakani et al., 2020), but further research is needed, especially with the adverse effect profile for these agents. See Table 5. Table 5: Off-Label Antipsychotic Use for Treating Anxiety Disorders
FDA Approved Anxiety Disorders
Off-Label Uses
Therapeutic Dose Range
Medication
Olanzapine (Zyprexa) Quetiapine (Seroquel)
None
Anxiety, GAD Anxiety, GAD
5-15 mg/day
None
50-300 mg/ day
Trifluoroperazine
Short-term anxiety symptom management
GAD, PD, SAD
2-6 mg/day
to develop tolerance to the drug’s anxiolytic effects over time. Due to hydroxyzine’s risk for anticholinergic toxicity and causing delirium, hydroxyzine may not be appropriate for managing anxiety disorders in the elderly or patients with a cognitive disorder. Common side effects of hydroxyzine are anticholinergic effects such as constipation, dry mouth, and sedation. Caution patients on the risks of driving or operating heavy machinery while taking hydroxyzine, especially in the first few days of treatment.
ALPHA- AND BETA-ADRENERGIC AGENTS
Propranolol (Inderal LA, Innopran XL) is a beta blocker commonly used for treating multiple indications, including atrial fibrillation, hypertension, migraine prophylaxis, essential tremor, and angina. It is also used off-label for anxiety (including performance anxiety, a subset of social anxiety disorder), PD, and SAD
(Garakani et al., 2020). Therapeutic dose range is 60–120 mg/ day. There has been some research into clonidine, an alpha-2 receptor agonist, for use in managing GAD and PD, but it wasn’t found to have much use in a clinical setting (Garakani et al., 2020).
GABAERGIC MEDICATIONS
Benzodiazepines Prescribing patterns of benzodiazepines have met increased scrutiny over recent years, but they remain among the most widely prescribed psychiatric medications in the world (Garakani et al., 2020). Benzodiazepines are no longer recommended for first-line monotherapy in treating anxiety disorders. This drop in therapy standing may be attributed to potential risks for tolerance, dependence, and abuse or misuse. However, strong evidence showing superiority in efficacy and tolerability of first-line Alprazolam (Xanax) Alprazolam is the most commonly prescribed psychotropic medication in the United States (George & Tripp, 2021) and is frequently used for treating panic and anxiety disorders. It’s FDA-indicated to treat GAD, and panic disorders with or without agoraphobia. Effects are often felt within 30 minutes after taking a dose and can last for up to 6 hours (George & Tripp, 2021).
treatments like SSRIs over benzodiazepines is lacking, particularly for short-term use with respect to treating GAD (Garakani et al., 2020). There has been concern that chronic benzodiazepine use could carry a potential risk for dementia, but recent research has not supported this association (Osler & Jørgensen, 2020). Although no longer recommended as first-line agents for maintenance management of anxiety disorders, they remain useful medications for short-term or as-needed use in combination with SSRIs and SNRIs. For treating GAD, the recommended alprazolam dosing is as follows: ● Starting dose : 0.25 mg to 0.5 mg three times a day. ● Titration : Dose may be increased at intervals of every three to four days. ● Maximum daily dose : 4 mg, in divided doses. ● Use the lowest dose effective for the patient and assess the need for continued treatment.
EliteLearning.com/Pharmacy-Technician
Book Code: RPTTX2024
Page 117
Powered by FlippingBook