NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

Over the past five years, I have learned that anxiolytic medications like benzodiazepines are commonly prescribed to elderly patients with general anxiety disorders. It is important to carefully consider the benefits and risks entailed in its use. According to Drenth-van Maanen et al. (2019), the pharmacodynamic and pharmacokinetic effects of drugs in the elderly depend on signal transduction, homeostatic regulation, and the number of affinities of target receptor sites, as well as their comorbidities and decline in organ functions. Jain &Maruccan-Sullivan (2019) explained that elderly patients have decreased gastric emptying, intestinal blood flow, hepatic metabolism, creatinine clearance and plasma albumin, so the metabolism, excretion, distribution, and absorption of benzodiazepines are slow, with increased risk for cognitive impairment and sedation. Sobeski (2020) said that ageing decreases drug activation and renal clearance, increases half-life, transit, absorption time of drugs, drug sensitivity, and adverse effects of benzodiazepines due to altered physiological changes. I have seen Lorazepam cause more confusion, falls, hallucinations, and agitation in some of my elderly patients, and worsening of symptoms or rebound side effects should be reviewed.

Plan of care should include psychological evaluation, drug prescription that will not be abused or withdrawn and outweighs the benefits rather than the risks, and consideration of non-pharmacological therapy. Medical comorbidities and drug side effects may mimic anxiety disorders, and proper symptom or clinical presentation assessments are necessary. Rosenthal &Burcham (2019) discussed that generalized anxiety disorders can be controlled with relaxation training, biofeedback, supportive or cognitive behavior therapy, selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and benzodiazepines medications. Subramanyam et al. (2018) explained that SSRI like Sertraline and Escitalopram are the first line of drugs, SNRI like Duloxetine and Venlafaxine are the second line, and benzodiazepines like Diazepam and Alprazolam should be tapered for short term use and may result in paradoxical agitation or neurocognitive effects like alcohol. Non-pharmacological treatment of anxiety is first recommended rather than pharmacological approaches such as socialization, sleep, environmental interaction, guided imagery, music or art therapy, mindfulness, and nutrition or electrolyte balance. Initiation of fall risk protocol, proper drug dosing, and monitoring of drowsiness, unsteadiness, addiction, and adverse anxiolytic drug effects should also be part of the personalized care plan.

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NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder References

Drenth‐van Maanen, A., Wilting, I., & Jansen, P. F. (2019). Prescribing medicines to older people – how to consider the impact of

ageing on human organs and body functions. British Journal of Clinical Pharmacology, 86(10), 1921–1930.

https://doi.org/10.1111/bcp.14094

Jain, N., &Maruca-Sullivan, P. (2019). Geriatric psychopharmacology prescribing medications in the elderly [PDF]. UCONN Health.

https://portal.ct.gov/-/media/DMHAS/SWS/olderadults/conference2019/GeriatricsPsychoPharmacologypdf.pdf

Rosenthal, L. D., &Burchum, J. R. (2021). Lehne’spharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.)

St. Louis, MO: Elsevier
Sobeski, L. (2020). Aging physiology, pharmacokinetics & pharmacodynamics [PDF]. UNMC College of pharmacy.

https://www.unmc.edu/NebraskaGWEP/wp-content/uploads/2020/GWEP_Medication_May-2020-Sobeski.pdf

Subramanyam, A. A., Kedare, J., Singh, O. P., & Pinto, C. (2018). Clinical practice guidelines forgeriatric anxiety disorders.

            Indian Journal of Psychiatry60(Suppl 3), S371–S382. https://doi.org/10.4103/0019-5545.224476

Among the anxiolytic medications for generalized anxiety disorder  (GAD) are benzodiazepines (BZDs). Concerning their

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

pharmacodynamic (PD) profiles, BZDs primarily target the γ-aminobutyric acid type A (GABAa) receptor. GABAa receptor is a ligand-gated ion (chloride) channel that is activated by GABA (Scherf-Clavel et al., 2021). When the inhibitory GABArgic activity is stimulated by endogenous ligands, BZDs, or other drugs, it results in amnesia, sedation, ataxia, sleep, and calm feeling (anxiolysis). BZDs’ PD effects include sedation, psychomotor impairment, antiepileptic actions, anterograde amnesia, and muscle relaxation. GABAergic system attenuation leads to restlessness, anxiety, insomnia, and exaggerated reactivity. The elderly are more affected by BZD’s sedation and psychomotor impairment (Neft et al., 2020). With regards to gender, females have higher plasma concentrations of zolpidem and thus, more psychomotor impairment effects. Thus, low dosages of BZD are recommended for females and the elderly. BZDs’ pharmacokinetics (PK) profiles are influenced by their different physiochemical properties particularly lipid solubility and absorption and diffusion rates. BZDs pass through the blood-brain barrier to equilibrate with the brain tissues (Oka et al., 2021). The two main BDZ biotransformation pathways include oxidation of hepatic microsome, hydroxylation of N-dealkylation or aliphatic hydroxylation, and glucuronide conjugation. The kidney excretes the metabolites. Most BZD’s hydroxylated metabolites are pharmacologically active, with some having long half-lives. The hydroxylation involves various specific enzymes with the main being CYP3A4 and CYP3A5 and CYP2C19, and CYP (Neft et al., 2020).

Another treatment that can be used is selective serotonin reuptake inhibitors (SSRIs). SSRIs block the reuptake of serotonin into neurons, increasing the serotonin available to enhance message transmission between neurons. SSRIs are selected as they main affect serotonin, a neurochemical that regulates mood and anxiety but does not affect other neurotransmitters such dopamine, GABA, or noradrenaline (Kapoor, 2021). SSRIs are newer anxiolytic compared to BZDs. However, despite their usefulness in treating anxiety, SSRIs are known to have delays in the onset of therapeutic effects and can exacerbate anxiety in early treatment (Kapoor, 2021). BZDs on the other hand, have a rapid onset of action but have tolerance and dependence concerns. Thus when prescribing anxiolytics, their PD and PK must be taken into account (Scherf-Clavel et al., 2021).

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder References

Kapoor, A. (2021). Pharmacokinetics and Pharmacodynamics. In Absolute Geriatric Psychiatry Review (pp. 197-206). Springer, Cham.https://doi.org/10.1007/978-3-030-58663-8_24

Neft, M. W., Oerther, S., Halloway, S., Hanneman, S. K., & Mitchell, A. M. (2020). Benzodiazepine and antipsychotic medication use in older adults. Nursing Open7(1), 4.doi: 10.1002/nop2.425

Oka, S., Satomi, H., Sekino, R., Taguchi, K., Kajiwara, M., Oi, Y., & Kobayashi, R. (2021). Sedation outcomes for remimazolam, a new benzodiazepine. Journal of Oral Science63(3), 209-211.https://doi.org/10.2334/josnusd.21-0051

Scherf-Clavel, M., Weber, H., Deckert, J., &Erhardt-Lehmann, A. (2021). The role of pharmacogenetics in the treatment of anxiety disorders and the future potential for targeted therapeutics. Expert Opinion on Drug Metabolism & Toxicology17(11), 1249-1260.https://doi.org/10.1080/17425255.2021.1991912

You made very good points, regarding different anxiolytic drugs for generalized anxiety disorder, such as benzodiazepines and selective serotonin reuptake inhibitors (SSRIs), to treat this disorder. It is true that benzodiazepines work quicker but tolerance develops whereas SSRIs take longer to work but do not have a potential for tolerance. It is interesting though how both of these types of drugs should not be dropped abruptly but must be tapered.

I believe that there are a couple of things that can interfere with treatment and processes for people with this disorder. For one, pain is a big concern. In fact, research shows that people with this disorder tend to share that they have somatic pain frequently (Teh et al., 2009). Some of these reports include chronic back pain as well as arthritis (Teh et al., 2009). Additionally, people with this disorder tend to complain more of a painful condition by about two or three times that of people without this disorder (Teh et al., 2009). Therefore, the drugs may not work as well if patients are dealing with pain issues at the receptor sites.

Additionally, I worked in a residential facility with women who had psychological disorders, such as generalized anxiety disorder, and alcohol and drug addiction. I was an addiction counselor for approximately 15 years prior to going into nursing and discovered that many women self-medicated with alcohol and/or illegal drugs to help cope. This can also interfere with pharmacokinetics and pharmacodynamics because illegal substances alter your thinking and behavior and there becomes competition for receptor sites when trying to use both illegal substances and prescribed drugs, which many of the patients I saw shared that they did.

You mentioned some treatment options, such as cognitive behavioral therapy (CBT). Randomized control trials revealed that participating in activities, such as CBT and yoga were very high compared to other non-drug treatment methods (Szuhany et al., 2022). In fact, 40% preferred yoga whereas 44% preferred CBT (Szuhany et al., 2022). I’m sure that release of neurotransmitters, such as gamma-aminobutyric acid (GABA) and endorphins play a part of this.

Thank you for sharing.

Szuhany, K. L., Adhikari, S., Chen, A., Lubin, R. E., Jennings, E., Rassaby, M., Eakley, R., Brown, M. L., Suzuki, R., Barthel, A. L., Rosenfield, D., Hoeppner, S. S., Khalsa, S. B., Bui, E., Hofmann, S. G., & Simon, N. M. (2022). Impact of preference for yoga or cognitive behavioral therapy in patients with generalized anxiety disorder on treatment outcomes and engagement. Journal of Psychiatric Research153, 109–115. https://doi.org/10.1016/j.jpsychires.2022.07.008

Links to an external site.

Teh, C. F., Morone, N. E., Karp, J. E., Belnap, B. H., Zhu, F., Weiner, D. K., & Rollman, B. L. (2009). Pain interference impacts response to treatment for anxiety disorders. Depression and Anxiety26(3), 222–228. https://doi.org/10.1002/da.20514