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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

Anxiety is a type of medical condition whereby the person feels worried, uneasy, nervous, or stressed. According to the American Psychiatric Association, anxiety is defined as an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V) classifies anxiety disorders into several main types such as generalized anxiety disorder, panic anxiety, and selective mutism.

Generalized anxiety disorder (GAD) is a type of anxiety that makes a person feel constantly worried. These worrying feelings are about anything and they can last for more than six months. Other symptoms of GAD include nausea, fatigue, trembling, urinating often, sweating hot flashes, irritability, and trouble breathing (Andrews et al., 2010). People diagnosed with GAD are subjected to psychotherapy and medical treatment. The medications used to treat GAD are classified as anxiolytic medications which are a group of drugs used to prevent or treat anxiety symptoms or disorders. They are sometimes called anti-anxiety medications or minor tranquilizers. Anxiolytic medications are habit-forming and can lead to dependency or a substance use disorder. For this reason, they’re often only prescribed for a short amount of time. Some of the anxiolytic medications include SSRIs (sertraline, fluoxetine, paroxetine, and citalopram). Selective serotonin-norepinephrine reuptake inhibitors (SNRI) such as Venlafaxine and Duloxetine have been approved by FDA as a treatment for GAD. Benzodiazepines (alprazolam) and other types of anxiolytic medications such as Second-generation antipsychotics (SGAs).

Before prescribing these drugs to any patient, it is important to understand their pharmacokinetics and pharmacodynamics. For example, the pharmacokinetics and pharmacodynamics of benzodiazepines involve the increase of g-aminobutyric acid (GABA) inhibitory impulses in the central nervous system mediated via benzodiazepine receptors. GABA blocks other activity in your brain, which helps you feel calm and can make you sleepy.

The structure of benzodiazepines is made up of a benzene ring fused to a seven-membered 1,4 diazepine ring. Alprazolam is administered orally and is directly metabolized by hepatic microsomal oxidation (Jahn et al., 2016). They have a peak plasma concentration which occurs after 1 to 2 hours of being taken. Another drug is chlordiazepoxide which although itself has an intermediate half-life (6 — 28 h), its active metabolite desmethyldiazepam has a very long half-life; oral chlordiazepoxide is rapidly and completely absorbed and its volume of distribution varies from 0.25 to 0.50 l/kg. The drug seems to block electroencephalogram arousal from stimulation in the brain stem reticular formation.

Another type of anxiolytic drug that has been approved to treat GAD is the Selective serotonin reuptake inhibitor (SSRI) drug that works by inhibiting serotonin reuptake transporter and this inhibition of the 5-HT increases the concentration of synaptic hence increasing the extra-synaptic diffusion. An example of SSRIs is fluoxetine which is metabolized through the CYP2D6 system, inhibits CYP2D6 activity, and exhibits considerable intra-individual variability in tolerability and response (Strawn et al., 2018). It also has noradrenergic and dopaminergic effects which putatively underlie its therapeutic efficacy. SNRI is another type of anxiolytic drug used for treating GAD. An example of SNRI such as venlafaxine has been approved by Food Drug Administration to treat GAD. The pharmacokinetics and pharmacodynamics of venlafaxine work through active metabolite, o-desmethylvenlafaxine by inhibiting the serotonin and norepinephrine reuptake transporters albeit with greater potency at the norepinephrine transporter (Gravelle, 2016). Duloxetine has been approved by the FDA to treat GAD. Its pharmacodynamics and pharmacokinetics include the reuptake inhibition of serotonin and norepinephrine at the presynaptic neuron in Onuf’s nucleus of the sacral spinal cord ( ).

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Another group of anxiolytic medications used is Non-benzodiazepine Sedative-Hypnotics such as eszopiclone which works by interaction with GABA receptor complexes at binding domains located close to or allosterically coupled to benzodiazepine receptors. Other types of anxiolytic medications are Second-generation antipsychotics (SGAs), Antihistamines, GABA-related interventions, and Tricyclic Antidepressants.

In conclusion, the choice of anxiolytic drug to be prescribed is dependent on the pharmacokinetics and pharmacodynamics factors that might affect the efficacy of the drug. It has been observed that SSRIs and SNRIs are considered the most effective while benzodiazepine and other types of drugs come second. An expert opinion argues that there is a need for healthcare providers to take an optimal pharmacological approach towards integrative pharmacokinetic and pharmacodynamics optimization strategy that would ensure better treatment and personalization of anxiety disorders. According to Almatura et al. (2013), this approach would help in the development of new anxiolytic drugs that are more effective and have limited side, especially benzodiazepines drugs.

 References

Altamura, A. C., Moliterno, D., Paletta, S., Maffini, M., Mauri, M. C., &Bareggi, S. (2013). Understanding the pharmacokinetics of anxiolytic drugs. Expert opinion on drug metabolism & toxicology9(4), 423-440.

Gravielle, M. C. (2016). Activation-induced regulation of GABAA receptors: is there a link with the molecular basis of benzodiazepine tolerance?. Pharmacological Research109, 92-100.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy19(10), 1057-1070.

Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., … & Stanley, M. A. (2010). Generalized worry disorder: a review of DSM‐IV generalized anxiety disorder and options for DSM‐V. Depression and anxiety, 27(2), 134-147.

Jann, Michael W.; Penzak, Scott R.; Cohen, Lawrence J. (2016). Applied Clinical Pharmacokinetics and Pharmacodynamics of Psychopharmacological Agents || Clinical Pharmacokinetics and Pharmacodynamics of Anxiolytics and Sedative/Hypnotics. , 10.1007/978-3-319-27883-4(Chapter 10), 247–266. doi:10.1007/978-3-319-27883-4_10 

Response

This is an in-depth discussion post. Indeed, the treatment of GAD entails both psychotherapy and pharmacotherapy. Essentially, multimodal approaches involving psychotherapy and pharmacotherapy in the management of GAD may distinctively focus on specific symptoms and the inclusion of psychotherapy enhances compliance with treatment and reduces reported adverse effects of pharmacotherapy. Understanding the principles of pharmacokinetics and Pharmacodynamics in the management of GAD is critical in the helping healthcare professionals to make informed decisions about medication formulation and dosage needs (Abuhelwa et al., 2022). It also crucial in building treatment plans entailing medications. The other potential treatment option in this case is psychotherapy. This options involves psychological counseling or talk therapy (Lamb et al., 2019). Here, a patient is expected to work with a therapist to minimize the anxiety symptoms. The popular form of psychotherapy for GAD is cognitive behavioral therapy (CBT). Psychotherapy is CBT aims at teaching particular skills to directly control the patent’s worries and help the patient to slowly return to that had been previously avoided due to anxiety.

References

Abuhelwa, A. Y., Somogyi, A. A., Loo, C. K., Glue, P., Barratt, D. T., & Foster, D. J. (2022). Population pharmacokinetics and pharmacodynamics of the therapeutic and adverse effects of ketamine in patients with treatment‐refractory depression. Clinical Pharmacology & Therapeutics. https://doi.org/10.1002/cpt.2640

Lamb, T., Pachana, N. A., & Dissanayaka, N. (2019). Update of recent literature on remotely delivered psychotherapy interventions for anxiety and depression. Telemedicine and e-Health, 25(8), 671-677. https://doi.org/10.1089/tmj.2018.0079

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

Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.

Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA approved indications when referring to different medication classes used in the treatment of GAD.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare:

  • Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
  • Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
  • Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
  • Think about a personalized plan of care based on these influencing factors and patient history with GAD.

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.

Generalized Anxiety Disorder (GAD) has been discovered as a widespread illness affecting many Americans in the United States. Medication to treat anxiety disorders, such as anxiolytics, is a subject of ongoing research. As for the pharmacodynamics of anxiolytics, these are drugs for mental health that typically affect the brain’s neurotransmitters. To relieve mood and anxiety symptoms, the drugs make sure synapses are firing. As for pharmacokinetics, the body quickly absorbs the drug before completely metabolizing it (Katzung & Trevor, 2017).

According to available data, GAD can be successfully treated with anxiolytics such as selective serotonin reuptake inhibitors (SSRIs), which include citalopram, sertraline, paroxetine and escitalopram. In such drugs you find they are well absorbed mostly in the gastrointestinal tract until they reach peak concentrations then they are metabolized. For their pharmacodynamics they inhibit reuptake of serotonin thus increasing its activity (Rosenthal & Burchum, 2020).

Studies have also shown that various anxiolytics, such as venlafaxine, duloxetine that are part of  serotonin norepinephrine reuptake inhibitors (SNRIs), as well as dopamine norepinephrine reuptake inhibitors are efficient therapies for GAD. Here they are majorly metabolized in the liver then bound to plasma proteins as they have large volume distributions and their peak plasma levels can be achieved in 2-10 hours. For pharmacodynamics they increase levels of dopamine, norepinephrine, and serotonin through blocking transport proteins and stopping their reuptake at the presynaptic terminal (Rosenthal & Burchum, 2020).

There are additional drugs that can be utilized to treat anxiety but are not categorized as anxiolytics. Antidepressants are frequently used concurrently to treat depression and anxiety in addition to treating anxiety. Thus, antidepressants may be beneficial in the management of GAD. Providers are recommending cannabis more frequently than ever before to treat anxiety problems. Compared to studies on anxiety medications, there is little study on cannabis’ effects. In contrast, research indicates that greater cannabis use may exacerbate anxiety. Antipsychotic drugs, like quetiapine, for instance, have the ability to lessen the symptoms of anxiety (Hoge & Fricchione, 2012).

Antipsychotics cannot currently be prescribed for anxiety, according to the FDA. Antihistamines offer calming effects that can reduce anxiety. Although Benadryl is most typically used as an antihistamine to treat allergies, it can also be used as a mild anxiolytic and antiemetic. I’ve used benzodiazepines in the past, such as diazepam and lorazepam, as a last choice for patients who want drugs for anxiety in order to avoid habit formation. Antihistamine hydroxyzine is frequently provided on an as-needed basis to patients who complain of anxiety. If administered late enough, this medicine is quite helpful and aids the patient in getting a decent night’s sleep (Cuijpers et al., 2014).

 

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

 

Generalized anxiety disorder (GAD) is among the most common mental health disorders, which makes those affected have undesirable symptoms such as anxiety, sweating, difficulty sleeping, and rapid breathing, among others. Anxiolytic medications have been used for a long time as a treatment modality for GAD(Fagan & Baldwin, 2023). An example of such a medication is Buspirone. Effective use of such medications requires that a practitioner develops an adequate understanding of the pharmacodynamics and pharmacokinetics related to them. For example, Buspirone is known to work through the inhibition of serotonin release. Such an action decreases the activation of postsynaptic serotonin receptors (Rosenthal et al.,2021). As such, the patient’s GAD symptoms and mood substantially improve. The medication is orally administered and has no abuse potential since it’s not sedative. It is also known that renal and hepatic impairment causes an enhanced amount of serum BuSpar in the bloodstream. However, factors like gender and age play no substantial role in Buspirone pharmacokinetics.

Other Treatment Options

Apart from the use of anxiolytic medications, there are also other medication classes used in the treatment of GAD. For example, Serotonin and norepinephrine reuptake inhibitor (SNRI) and selective serotonin reuptake inhibitor (SSRI), which are antidepressants, have been used widely in the treatment of GAD. Some of the medications used in this class include escitalopram and paroxetine (Kaveiy et al., 2023). As opposed to anxiolytics, these classes of drugs act by inhibiting the reuptake of neurotransmitters through selective receptors. As such, the reuptake increases the concentration of particular neurotransmitters around the nerves in the brain. Benzodiazepines have also been used to a lower extent. These medications have sedative properties and are used to help relieve acute anxiety symptoms in the short term. In comparison to anxiolytics, these medications are effective in relieving the symptoms. However, they may enhance habits such as drug abuse.

References

Fagan, H. A., & Baldwin, D. S. (2023). Pharmacological Treatment of Generalised Anxiety Disorder: Current Practice and Future Directions. Expert Review of Neurotherapeutics, 1–14. https://doi.org/10.1080/14737175.2023.2211767

Kaveiy, M., Toozandejani, H., Taher, M., & Zendehdel, A. (2023). Comparing the effectiveness of modular cognitive-behavioral therapy,‎‏‏ pharmacotherapy (paroxetine) and their combination in intolerance of uncertainty and meta-worry‎ in female university students with generalized anxiety disorder. Razavi International Journal of Medicine11(1). https://dx.doi.org/10.30483/rijm.2023.254446.1263

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.