By Day 3 of Week 8
Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.
By Day 6 of Week 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!
Sample Answer 3 for NURS 6521 Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
Hello Sara, your post provides a comprehensive overview of Generalized Anxiety Disorder (GAD) and the pharmacological treatments used to manage it, specifically benzodiazepines, Buspirone and venlafaxine. It’s important to have a good understanding of these treatment options when dealing with GAD. Here are some key takeaways and additional information:
Generalized Anxiety Disorder (GAD): You’ve done an excellent job explaining what GAD is and how it can affect individuals. Mentioning that it’s more prevalent in women and that it can develop over time, starting in childhood or around the age of 30, adds valuable context
Highlighting the criteria for diagnosing GAD based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) is important (APA, 2023). It helps readers understand how healthcare providers make the diagnosis. You’ve correctly pointed out that GAD can have a genetic component and that experiencing traumatic events or being in a stressful environment can increase the risk. This information helps readers understand some of the potential causes. Your explanation of the pharmacokinetics and pharmacodynamics of benzodiazepines is informative (Mayo Clinic (2017). You’ve emphasized the importance of considering the risk of tolerance and abuse, especially in patients with a history of substance abuse. Additionally, you’ve mentioned the suitability of specific benzodiazepines for older adults (NCBI, 2023).
You’ve provided a clear description of buspirone’s characteristics, including its slower onset of action, lack of sedation, and its suitability for patients with substance abuse issues. The note on adjusting the dosage for patients with renal impairment is a valuable addition. In addition, you’ve highlighted the role of venlafaxine as a serotonin-norepinephrine reuptake inhibitor (SNRI) and its effectiveness in GAD treatment. The mention of its delayed onset of action and potential risks like suicide, particularly in younger patients, is crucial for readers to be aware of (Rosenthal, Laura D., et al., 2021).
Your conclusion provides an excellent summary of the factors that healthcare providers should consider when choosing a treatment approach for GAD. It underscores the need to individualize treatment based on a patient’s specific needs and circumstances.
In summary, your post offers a well-rounded discussion of GAD and its treatment options. It covers important aspects of diagnosis, risk factors, and the pharmacological treatment of GAD, allowing readers to better understand the condition and its management.
Reference
American Psychological Association (2023). PTSD guideline: What is exposure therapy? Retrieved October 19, 2023, from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapyLinks to an external site.Links to an external site.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier Inc.
Generalized Anxiety Disorder, www.ncbi.nlm.nih.gov/books/NBK279594/Links to an external site.. Accessed 19 Oct. 2023.
Mayo Clinic (2017). Generalized anxiety disorder. Retrieved October 19, 2023, from https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/diagnosis-treatment/drc-20361045Links to an external site.Links to an external site.
Sample Answer 4 for NURS 6521 Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) is a debilitating condition characterized by excessive and uncontrollable worry (Clemenza et al., 2018). It is an illness that often begins in childhood or early adulthood and persists throughout life. “GAD affects up to 5% of children and adolescents and between 3–6% of adults” (Clemenza et al., 2018, p. 1058). Anxiolytic medications are commonly prescribed for GAD, but an individualized treatment approach is crucial, considering the numerous factors that can affect pharmacokinetics and pharmacodynamics.
Pharmacogenetics is critical in determining the patient’s response to anxiolytic medications (Jancic et al., 2023). Genetic variations in drug-metabolizing enzymes and drug transporters can influence the rate of drug metabolism and bioavailability. For instance, individuals with specific CYP2D6 genetic variants may metabolize selective serotonin reuptake inhibitors (SSRIs) differently, potentially requiring dose adjustments or alternative medications. Therefore, pharmacogenetic testing is a valuable tool to guide treatment decisions and minimize adverse effects. Furthermore, gender differences can significantly impact the pharmacokinetics and pharmacodynamics of anxiolytic medications. For example, women generally metabolize drugs more slowly than men due to variations in body composition and hormonal fluctuations (Mattison & Soldin, 2009). This can result in differences in drug efficacy and side effects. It may be necessary to consider lower initial doses of medications, close monitoring for side effects, or preferential use of SSRIs, which may have a more favorable risk-benefit profile for some female patients.
Ethnicity can influence drug response due to variations in genetics and cultural factors. Certain ethnic groups may have different genetic polymorphisms, leading to differences in drug metabolism (Koenig et al., 2021). Additionally, cultural beliefs and practices can impact patient adherence to medications. Moreover, age-related changes in pharmacokinetics and pharmacodynamics are significant considerations for GAD treatment. Elderly patients may experience altered drug metabolism and an increased risk of adverse effects (Cassidy & Sheikh, 2000). This population may benefit from medications with a more predictable safety profile, such as SSRIs or serotonin-norepinephrine reuptake inhibitors (SNRIs), over benzodiazepines. Lower initial doses may also be appropriate for older patients to minimize side effects and prevent excessive sedation.
Patient behavior and lifestyle choices can have a substantial impact on treatment effectiveness. Substance use, including alcohol and illicit drugs, can interact with anxiolytic medications and alter their effects (Brady et al., 2013). Non-pharmacological interventions, like cognitive-behavioral therapy (CBT) and relaxation techniques, should be integrated into the patient’s care plan to address the behavioral aspects of GAD and enhance the effectiveness of pharmacotherapy.
Coexisting medical conditions can influence the pharmacokinetics and pharmacodynamics of anxiolytic medications. Patients with GAD and comorbid diseases like liver or kidney impairment may require dose adjustments to ensure therapeutic drug levels and prevent toxicity (Menon et al., 2022). Additionally, individuals with GAD often experience comorbid depression, which may necessitate a tailored approach to medication selection, favoring agents effective for both conditions (Clemenza et al., 2018).
A comprehensive, personalized care plan for a patient with Generalized Anxiety Disorder (GAD) should consider various influencing factors to optimize treatment outcomes. Firstly, pharmacogenetic testing should be prioritized to identify genetic variations in drug metabolism, enabling the selection of the most suitable medications and dosages tailored to the patient’s unique genetic profile (Jancic et al., 2023). Additionally, gender-specific considerations should be considered, with lower initial medication doses and close monitoring of potential side effects for female patients, and the consideration of Selective Serotonin Reuptake Inhibitors (SSRIs) as a first-line treatment option (Mattison & Soldin, 2009). Moreover, ethnicity-specific adaptations are essential, customizing medication choices and dosages based on the patient’s ethnicity and considering genetic and cultural factors (Koenig et al., 2021). For elderly patients, a preference for medications with a predictable safety profile, initiating treatment with lower doses, and careful assessment for side effects is crucial (Cassidy & Sheikh, 2000). Behavioral interventions should also be integrated into the care plan, combining anxiolytic medications with psychotherapy, such as Cognitive-Behavioral Therapy (CBT), and encouraging the adoption of healthy lifestyle choices to address the behavioral aspects of GAD (Brady et al., 2013). Lastly, disease-related adjustments should be made, considering any comorbid medical conditions to ensure that medication choices and dosages are adapted to the patient’s overall health.
When considering treatment options for Generalized Anxiety Disorder (GAD), providers need to consider various factors, such as genetics and age, and each medication’s positive and negative aspects. Benzodiazepines are effective for rapidly alleviating anxiety symptoms, making them suitable for short-term, acute anxiety episodes or as bridge therapy while awaiting the onset of action of SSRIs (Clemenza et al., 2018). However, they carry the risk of dependence and withdrawal symptoms. They can cause sedation, dizziness, and impaired cognitive function, discouraging long-term use due to the potential for tolerance and addiction.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are generally considered first-line treatments for GAD due to their safety and efficacy (Clemenza et al., 2018). They have a lower potential for dependence and addiction than benzodiazepines and are suitable for long-term use. However, their onset of action is slower, often taking several weeks to show therapeutic effects. They may also cause side effects, such as nausea, sexual dysfunction, or weight changes, and genetic factors, like CYP2D6 variations, can influence their metabolism and response (Jancic et al., 2023 & Mayo Clinic, n.d.).
Buspirone provides a non-habit-forming anxiolytic option for GAD. It is suitable for patients who cannot tolerate or prefer to avoid benzodiazepines or SSRIs and can be used as an add-on therapy to SSRIs or SNRIs for enhanced efficacy (Cassidy & Sheikh, 2000). However, it has a slower onset of action compared to benzodiazepines and may be less effective in severe cases of GAD (Gale & Oakley-Browne, 2000). Additionally, buspirone was found to cause more nausea, dizziness, and drowsiness when compared to a placebo.
Combination therapy can simultaneously address multiple aspects of GAD and enhance treatment response, particularly in treatment-resistant cases (Ansara, 2020). It may reduce the need for higher doses of a single medication. However, it increases the risk of drug-drug interactions and side effects, requiring careful monitoring and potential dose adjustments. This approach may also complicate treatment regimens and reduce patient adherence.
Cognitive-behavioral therapy (CBT) and behavioral interventions address GAD’s behavioral and psychological aspects (Ansara, 2020). They effectively teach patients coping skills and anxiety management techniques and can be used alone or as an adjunct to pharmacological treatment. However, they do not provide immediate relief from symptoms and may be less effective in individuals with severe GAD without concurrent pharmacotherapy. Patient engagement is crucial, and these approaches may only suit some. Therefore, the treatment choice for GAD should be individualized, considering each patient’s unique characteristics and preferences.
References
Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician, 10(6), 326–334. Retrieved October 17, 2023, from https://doi.org/10.9740/mhc.2020.11.326Links to an external site.
Brady, K. T., Killeen, T. K., Hartwell, K. J., & Haynes, L. F. (2013). Substance use disorders and anxiety: A treatment challenge for social workers. Social Work in Public Health, 28(3-4), 407–423. Retrieved October 17, 2023, from https://doi.org/10.1080/19371918.2013.774675Links to an external site.
Cassidy, E. L., & Sheikh, J. I. (2000). Treatment of anxiety disorders in the elderly. Journal of Anxiety Disorders, 14(2), 173–190. Retrieved October 17, 2023, from https://doi.org/10.1016/s0887-6185(99)00047-xLinks to an external site.
Clemenza, K., Geracioti, L., Levine, A., Rajdev, N., & Strawn, J. R. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057–1070. Retrieved October 17, 2023, from https://doi.org/10.1080/14656566.2018.1491966Links to an external site.
Gale, C., & Oakley-Browne, M. (2000). Extracts from “clinical evidence”: Anxiety disorder. BMJ, 321(7270), 1204–1207. Retrieved October 17, 2023, from https://doi.org/10.1136/bmj.321.7270.1204Links to an external site.
Jancic, J., Radosavljevic, M., Samardzic, J., & Svob Strac, D. (2023). The role of pharmacogenetics in personalizing the antidepressant and anxiolytic therapy. Genes, 14(5), 1095. Retrieved October 17, 2023, from https://doi.org/10.3390/genes14051095Links to an external site.
Koenig, J., Olafuyi, O., Parekh, N., & Wright, J. (2021). Inter‐ethnic differences in pharmacokinetics—is there more that unites than divides? Pharmacology Research & Perspectives, 9(6), e00890. Retrieved October 17, 2023, from https://doi.org/10.1002/prp2.890Links to an external site.
Mattison, D. R., & Soldin, O. P. (2009). Sex differences in pharmacokinetics and pharmacodynamics. Clinical Pharmacokinetics, 48(3), 143–157. Retrieved October 17, 2023, from https://doi.org/10.2165/00003088-200948030-00001Links to an external site.
Mayo Clinic. (n.d.). Selective serotonin reuptake inhibitors (SSRIs). Retrieved October 17, 2023, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825Links to an external site.
Menon, V., Praharaj, S., & Ransing, R. (2022). Management of psychiatric disorders in patients with hepatic and gastrointestinal diseases. Indian Journal of Psychiatry, 64(8), 379. Retrieved October 17, 2023, from https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_18_22Links to an external site.
Sample Answer 5 for NURS 6521 Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
The way you approached and articulated the discussion is commendable on generalized anxiety disorder (GAD) and the pharmacological approaches to treatment. Indeed, selective serotonin reuptake inhibitors and Serotonin Norepinephrine Reuptake Inhibitors (SNRI) are considered first-line treatments. The medications are effective and well tolerated, with usually manageable or short-lived adverse effects. However, sexual dysfunction is often long-lived, and problematic adverse effects with SNRIs and SSRIs are often manageable with adjunct treatment (Garakani et al., 2020). It is essential to consider that SSRIs and SNRIs were developed as antidepressants, and emerging evidence supported their use in anxiety disorders. They are effective in comorbid depression and anxiety but equally effective as anxiolytics, even in the absence of a depression (Rosenthal and Burchum, 2020).
In alternative treatment, antihistamines, particularly hydroxyzine and diphenhydramine, have been shown to be effective in anxiety disorders, with comparable effectiveness to benzodiazepines. However, it is essential to note that while they offer safer alternatives to benzodiazepines in children and pregnant women, there as significant safety concerns in older adults. Notably, antihistamines pose a high risk of anticholinergic toxicity or delirium in older adults or patients with neurocognitive disorders (Gakarani et al., 2020). According to Stahl (2020), hydroxyzine should be avoided in older adults, especially in dementia. Regarding the use of cannabis, while there is a lack of research on its use in GAD, emerging evidence shows it has no significant clinical benefit. In a study that included 5,075 on cannabis, 90% did not experience significant improvement based on the GAD-7 score over an average of 282 days of follow-up. Only 3.7% had a clinically significant decrease (Lee et al., 2022). Still, there are significant safety concerns about using cannabis for anxiety. According to Stanciu et al. (2021), medical cannabis should not be recommended for treating patients with anxiety disorders, with the concern of worsening anxiety disorders and inducing psychotic symptoms.
References
Garakani, A., Murrough, JW., Freire, RC., Thom, RP., Larkin, K., Buono, FD., & Iosifescu, DV. (2021). Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Focus (American Psychiatric Publishing), 19(2), 222–242. https://doi.org/10.1176/appi.focus.19203Links to an external site.
Lee, C., Round, JM., Klarenbach, S., Hanlon, JG., Hyshka, E., Dyck, J. RB., & Eurich, DT. (2021). Gaps in evidence for the use of medically authorized cannabis: Ontario and Alberta, Canada. Harm reduction journal, 18(1), 61. https://doi.org/10.1186/s12954-021-00509-0Links to an external site.
Rosenthal, LD., & Burchum, JR. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants – E-Book. Elsevier Health Sciences. Kindle Edition.
Stanciu, C. N., Brunette, M. F., Teja, N., & Budney, A. J. (2021). Evidence for Use of Cannabinoids in Mood Disorders, Anxiety Disorders, and PTSD: A Systematic Review. Psychiatric services (Washington, D.C.), 72(4), 429–436. https://doi.org/10.1176/appi.ps.202000189Links to an external site.
Sample Answer 6 for NURS 6521 Discussion: Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
The name “generalized” anxiety disorder (GAD) comes from the fear of many things rather than just a few. Generalized anxiety disorder (GAD) is a chronic condition characterized by persistent and long-lasting anxiety that typically starts in early adulthood or adolescence and continues throughout an individual’s life (Rosenthal & Burchum, 2021). Visible behaviors include an intense preoccupation with everyday occurrences and the manifestation of somatic and bodily symptoms like tiredness, muscle tightness, and a rapid heartbeat (Rosenthal & Burchum, 2021).
Pharmacokinetics and pharmacodynamics
Anxiolytics are drugs used for mental health primarily target neurotransmitters in the brain. The drugs facilitate the activation of synapses to enhance mood and alleviate feelings of anxiety (He, Xiang, Gao, Bai & Fan, 20190). Anxiety can be debilitating, but there are several therapies available to treat GAD.
Non-Drug Therapy
Therapy that does not include the use of drugs can be used to treat GAD. Supportive therapy, cognitive behavioral therapy (also known as CBT), biofeedback, and relaxation training are examples of alternatives to pharmacological treatment. These things can be helpful in relieving symptoms and improving coping skills in situations that trigger anxiety. When symptoms are relatively minor, treatment using non-drug methods may be sufficient (Rosenthal & Burchum, 2021).
Cannabis
Dragioti, Solmi, Favaro, Fusar-Poli, Dazzan, & Thompson, (2019) posited that there has been an increase in the frequency with which healthcare providers are recommending cannabis to address anxiety problems. Although there is scarcity of study on the effects of cannabis in comparison to the extensive research conducted on medicine for anxiety. Conversely, it is shared by Dragioti et al, (2019) that heightened consumption of cannabis can result in heightened levels of anxiety.
Benzodiazepines
Rosenthal & Burchum, (2021) stressed that benzodiazipine can temporarily be used in the treatment extreme cases of GAD. The chemical structure of benzodiazepines is highly individualized and has consistent pharmacological properties. Due to their pharmacokinetics and metabolism, they should be used cautiously. These weak acids with high lipophilicity and variable constant dissociation cross membranes quickly (blood-brain and placental barriers, breast milk). Most benzodiazepines are water-insoluble chlordiazepoxide; dipotassium clorazepate, and midazolam, hence organic solutions must be employed for parenteral administration. Short-term anxiety alleviation is usually provided by these sedatives. These medications can be habit-forming, so they should be avoided in patients that misuse alcohol or narcotics. Benzodiazepines can be administered with SSRIs/SNRIs in the weeks before efficacy (Rosenthal & Burchum, 2021).
Tricyclic antidepressants (TCAs)
Antidepressants are commonly prescribed to alleviate anxiety symptoms and are frequently administered in conjunction with treatment for depression as well (Rosenthal & Burchum, 2021). These drugs do not fall within the category of anxiolytics. Antidepressants exhibit efficacy in the management of Generalized Anxiety Disorder (GAD). Imipramine and clomipramine are as effective as second-generation antidepressants that typically cause more side effects than SSRIs or SNRIs (He et al, 2019). Therefore, they should be tried before utilizing TCAs. The dosage should be progressively increased to depression therapeutic levels. TCAs can produce deadly toxicity if overdosed, thus suicidal patients should be cautious. All TCAs are readily absorbed and bind to plasma albumin with 90–95% affinity at therapeutic plasma concentrations after oral dosing. Their ability to attach to extravascular tissues gives them huge distribution volumes (10-50 l kg1). Plasma concentrations between 50 and 300 ng ml1 (molecular weights 263-314), are considered therapeutic (He et al, 2019).
Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs)
These are first-line drugs due to their favorable benefit-to-risk ratio. Patients should be advised that these antidepressants take 2–4 weeks (sometimes 6 weeks) to reduce anxiety. Adverse effects may worsen in the first two weeks (He et al, 2019). Initial jitteriness or anxiety may reduce treatment compliance. Lowering the antidepressant’s starting dose may reduce negative effects. Many SSRIs and SNRIs are cytochrome P450 enzyme inhibitors, therefore they may interact with other psychopharmacological drugs and medical treatments. After stopping SSRIs, withdrawal symptoms may occur. These are rarer and less severe than benzodiazepine withdrawal symptoms. These adverse effects may be more common with paroxetine than sertraline or fluoxetine (He et al, 2019).
Buspirone
Buspirone is FDA-approved for treating anxiety and is commonly used in conjunction with SSRIs or SNRIs, particularly for GAD. Only azapirone is approved in the US. According to He, et al (2019) buspirone is found to be less effective than benzodiazepines and antidepressants in the treatment of GAD. Buspirone has a strong first-pass effect and is mostly absorbed orally. A 10 mg dose reaches plasma peak in within an hour. Buspirone is excreted through urine and bile (Rosenthal & Burchum, 2021).
Conclusion
According to Sartori & Singewald (2019), both selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, citalopram, and escitalopram and serotonin norepinephrine reuptake inhibitors (SNRIs) like venlafaxine and duloxetine, as well as dopamine norepinephrine reuptake inhibitors such as bupropion are successful therapies for generalized anxiety disorder. However selective serotonin reuptake inhibitors (SSRIs) are favored over tricyclic antidepressants for depression and anxiety. Antipsychotic drugs such as Quetiapine (Seroquel) also have characteristics that alleviate feelings of anxiety (Rosenthal & Burchum, 2021).
References
Dragioti, E., Solmi, M., Favaro, A., Fusar-Poli, P., Dazzan, P.,& Thompson, T. (2019). Association of antidepressant use with adverse health outcomes: a systemic umbrella review:JAMA Psychiatry. 76:1241-55. doi:10.1001/jamapsychiarty.2019.2859.
He, H., Xiang, Y., Gao, F., Bai, L., & Fan, Y. (2019. Comparative efficacy and acceptability of fisrst-line drugs for the acute treatment of generalized anxiety diaorder in adults:a network meta-analysis: J Psychiatr Res. 118:21-30. doi:10.2016/j.jpsychires.2019.08.009.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier
Sartori, S.B., & Singewald, N.(2019). Novel Pharmacological targets in drug development for the treatment of anxiset and anxiety-related disorders: Pharmacol Thel 204:107402. doi:10.1016/j.pharmthera.2019.107402
