Anxiolytics: when? why? which one?

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From: Patient Care(Vol. 21, Issue 17)
Publisher: Intellisphere, LLC
Document Type: Article
Length: 3,662 words

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Anxiolytics: When? Why? Which one?


Comparing the benzodiazepines: The drugs most frequently prescribed to relieve anxiety symptoms are benzodiazepines. The most suitable candidate for therapy is the patient who displays a time-limited stress or generalized anxiety disorder. Categorized as either short- or long-acting, the benzodiazepines in each group are generally considered equally effective. Consider the patient's life-style and his or her physical and psychological characteristics before prescribing.

The relief of unpleasant symptoms and an increase in the patient's level of functioning are the goals of antianxiety thereapy, and individualization of thereapy is the key to success. Ideally, resolution of the causes of anxiety should be brought about with counseling or psychotherapy. However, pharmacologic agents also play an important role in the office treatment of anxiety. Benzodiazepines are the mainstay of pharmacologic antianxiety therapy.

Considering the number of antianxiety agents on the market, the task of selecting one for a particular patient seems formidable. You can narrow the field, however, by careful consideration of the patient's needs, his or her physical and psychological characteristics, and the nature of each pharmacologic agent (see "Anxiety: A wide clinical spectrum'). Just as fever is a sign of disease and not a diagnosis, so are anxious fellings often a sign of an underlying problem. The physician's task is to explore the nature and cause of the patient's discomfort, then to pursue the best therapeutic course (see "Questions to ask before prescribing an antianxiety agent,' page 62).

The most suitable candidates for benzodiazepine therapy are patients who are experiencing a time-limited stress or who have generalized anxiety disorder. Benzodiazepines may also reduce anticipatory anxiety in patients with panic disorder.

Benzodiazepines are categorized as long- or short-acting based on their pharmacokinetic profiles (see Table 1, page 69). Among the long-acting agents are chlordiazepoxide HCl (Librium), clorazepate dipotassium (Tranxene), diazepam (Valium), halazepam (Paxipam), and prazepam (Centrax). The short-acting benzodiazepines include alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax). Lorazepam and oxazepam are distinguished from other benzodiazepine anxiolytics by the fact that they produce no active metabolites and undergo simple one-step inactivation.

Short-acting benzodiazepines are a good choice for people who must remain alert, with the only practical difficulty being that the patient must take several daily doses. Lorazepam has a slightly faster onset of action than oxazepam, but otherwise these two drugs are equally effective. In a healthy adult, starting therapy with oxazepam is 10-15 mg bid. If this dosage fails to bring the patient enough relief, increase it to 10-15 mg tid or qid, and gradually to 30 mg tid or qid for severe anxiety. The usual initial dosage of lorazepam is 2-3 mg/d taken in two or three divided doses; if doses cannot be made equal conveniently, the largest should be taken before bedtime. If anxiety is severe, the dosage can be increased gradually to 10 mg/d; increase the evening dose before you increase the daytime doses.

A disadvantage of the short-acting drugs is that the patient may experience inter-dose anxiety. In addition, withdrawal syndromes...

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Gale Document Number: GALE|A6137097