Transcript PPT
Update on Pharmacotherapies for PTSD Michelle Pent, MD, MPH April 29, 2011 Presentation • Anxiety-spectrum disorder • DSM-IV criteria – A: Exposure to traumatic event with perceive threat to life or physical integrity and response of intense fear – B: Re-experience of the traumatic event – C: Avoidance of stimuli associated with the trauma – D: Hyperarousal Target Symptoms • • • • • • Intrusive ruminations Nightmares Flashbacks Hyperarousal Hypervigilance Associated irritability, anger, poor focus and concentration, and physiologic distress Neurochemistry • Amygdala • Central Nervous System – Norepinephrine, Serotonin, Dopamine, GABA • Peripheral Nervous System – Sympathetic Nervous System – “Fight or flight” Treatment • Psychotherapy • Pharmacotherapy • Most evidence suggests psychotherapy is most effective – CBT – EMDR – DBT where indicated Complimentary Treatments • • • • Yoga/Meditation Acupuncture Mindfulness Training Relaxation Therapy Pharmacotherapy • Objective is to improve symptoms by minimizing anxiety – Selective Serotonin Reuptake Inhibitors – Other antidepressants – Anxiolytics – Other Selective Serotonin Reuptake Inhibitors (SSRIs) • Raise serotonin levels in the brain • Remain standard of care for anxiety disorders • Linked with – Improvement in baseline level of anxiety – Diminished intrusive ruminations SSRIs • • • • • • Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Luvox) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) SSRIs • Lag time before efficacy – Usually 4-6 weeks – Adequate trial a minimum of 8 weeks • Side effects – Nausea, diarrhea – Weight gain – Agitation – Sexual dysfunction Other Antidepressants • Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) – Venlafaxine (Effexor) – Duloxetine (Cymbalta) – Desvenlafaxine (Pristiq) • Tricyclic Antidepressants – Amitryptyline (Elavil) – Doxepin (Sinequan) Anxiolytics • • • • Benzodiazepines Alpha adrenergic antagonists Buspirone Antihistamines Benzodiazepines • Diminish anxiety by enhancing GABA in the central nervous system • No longitudinal effect on anxiety • Significant tolerance and dependence – Essentially contraindicated in patients with history of substance abuse • Intended for short term use • Increasingly considered inappropriate for long term treatment of anxiety disorders Benzodiazepines • • • • • • • Diazepam (Valium) Lorazepam (Ativan) Alprazolam (Xanax) Clonazepam (Klonopin) Oxazepam (Serax) Chlordiazepoxide (Librium) Temazepam (Restoril) Other Anxiolytics • Buspirone (Buspar) – Serotonin agent – May cause headache, nausea • Antihistamines – Diphenhydramine (Benadryl) – Hydroxyzine (Vistaril) – Side effects include sedation, confusion at high doses Other Anxiolytics • Alpha adrenergic antagonists – Blood pressure medications – Prazosin (Minipress) – Clonidine (Catapres) – Side effects include dizziness and other complications of low blood pressure Other Anxiolytics • Gabapentin – Anticonvulsant/Mood Stabilizer – Enhances GABA in central nervous system – Some usefulness for anxiety – Limited addictive potential Use of Antipsychotics • May be useful as anxiolytics • Use does not necessarily imply psychosis • Significant sedation, weight gain, metabolic disturbance • Most commonly used – Quetiapine (Seroquel) – Olanzapine (Zyprexa) – Ziprasidone (Geodon) Treating Sleep Sleep • Review of sleep hygiene is critical • Complimentary treatments can also be effective Sleep • Benzodiazepine analogues – Eszopiclone (Lunesta) – Zolpidem (Ambien) – Addictive potential • Benzodiazepines – Short term use Sleep • Trazodone (Desyrel) – Often exacerbates nightmares • Mirtazapine (Remeron) – Associated with weight gain • Melatonin – Ramelteon (Rozerem) Sleep • Antihistamines • Alpha antagonists • Sedating antipsychotics – Seroquel, Zyprexa Choosing a Medication? • • • • Safety Tolerability Efficacy Cost • Educate patient that symptoms unlikely to improve with medication in the absence of psychotherapy Questions?