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

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

Generalized anxiety disorder is a chronic condition characterized by uncontrollable worrying, and of all anxiety disorders, GAD is the most least likely to remit (Rosenthal & Burchum, 2021). Depression is usually associated with GAD. According to Rosenthal & Burchum (2021), the hallmark of GAD is unrealistic or excessive anxiety about several events or activities. The FDA approved first-line medication choices include SSRI’s, SNRI’s and buspirone. The approved second line of medication is benzodiazepine. Antidepressants have a delay effect which can take several weeks to take effect, while benzodiazepine’s onset is rapid. The four main first-line medications include SSRI – Paroxetine (Paxil) & Escitalopram (Lexapro), SNRI – Venlafaxine (Effexor XR) & Duloxetine (Cymbalta).

Pharmacodynamics for SSRI’s according to Rosenthal & Burchum (2021), is by selectively blocking neuronal reuptake of serotonin 5-HT, a monoamine neurotransmitter. The reuptake concentration of 5-HT in the synapse increases, which activates the postsynaptic 5-ht receptors, this mechanism which is consistent with the theory that depression stems from a deficiency in monoamine-mediated transmission (Rosenthal & Burchum, 2021).

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Pharmacokinetics for SSRI’s, oral medication is well absorbed, even in the presence of food. They are metabolized by the liver primarily by CYP2D6, then followed by excretion in the urine (Rosenthal & Burchum, 2021). SSRI’s are known to cause sexual dysfunction including impotence and delayed orgasm, delayed ejaculation and decreased sexual interest. Weight gain is also associated with SSRI’s possibly due to the decreased sensitivity of 5-HT receptors that regulate appetite (Rosenthal & Burchum, 2021). MAOI’s are to be avoided when taking SSRI’s due to the risk of serotonin syndrome, which can be life threatening if left untreated.

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Pharmacodynamics for SNRI’s block the neuronal reuptake of serotonin and norepinephrine, with minimal effects of

other transmitters or receptors (Rosenthal & Burchum, 2021). The drug produces a powerful blockade of NE and 5HT reuptake and weak blockade of dopamine reuptake. There is evidence that SSRI’s are tolerated and considered safer to take.

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Pharmacokinetics for SNRI’s, orally they are well absorbed. The liver converts the medication to desvenlafaxine and active metabolite. The half-life is 5 hours for the parent drug and 11 hours for the active metabolite (Rosenthal & Burchum, 2021). SNRI’s are also known to cause sexual dysfunction. In addition, monitoring blood pressure is needed due to dose related diastolic hypertension. The patient will need to have their sodium levels monitored especially if taking a diuretic which will increase the chance of hyponatremia. As with SSRI’s MAOI’s will need to be avoided due to the risk of serotonin syndrome.

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In comparison according to Jakuboyski et al, (2018), higher doses of SSRIs within the therapeutic range are associated with greater treatment benefit, whereas higher doses of SNRIs are not.

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According to Ruhe et al, (2019), Because the prevalence of antidepressant withdrawal symptoms is unknown and not all patients require dose reductions to discontinue antidepressants, three risk-factors that are consistently reported in the literature to indicate an increased risk of antidepressant withdrawal symptoms: (1) dosing above the minimal effective dose to reach efficacy, (2) antidepressant withdrawal symptoms when a dose was missed or during strategic treatment interruption, and (3) earlier failed attempts to discontinue the SSRI or SNRI.

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Benzodiazepine, though the second line in treatment for anxiety due to the risk of dependence, is the first line for an acute anxiety attack. According to Rosenthal & Burchum (2021), benefits derive from enhancing responses to GABA, an inhibitory neurotransmitter. Benzodiazepines shoul