Benzodiazepines
Although some people seem to feel using benzodiazepines are a last resort, they really aren't. If used responsibly on a short-term basis, they are very effective anxiolytics. It is important to account for half-life and dosing equivalency. Long-term use is not good idea (except in some patients with schizophrenia who do not increase the dose). However, for the short term there is no reason not to use a benzodiazepine. They are not evil in that regard.
Benzodiazepines that are reasonable choices in medically ill patients for the treatment of anxiety are in subjective preference: lorazepam, clonazepam, oxazepam, diazepam, and chlordiazepoxide. In patients who are kept awake by anxiety, temazepam is a reasonable choice.
Benzodiazepines with rapid onset (e.g., alprazolam, diazepam) can be desirable in the treatment of anxiety, but tend to have a higher potential for dependence. It is important to consider the metabolism of benzodiazepines, especially in patients with extreme hepatic impairment. The effects of benzodiazepines can be cumulative, especially for medications with active long-half metabolites (e.g., diazepam).
★Notably, lorazepam and oxazepam have no active metabolites.
Diazepam, midazolam, and lorazepam can be administered parenterally. Lorazepam is the ideal choice for intramuscular administration because of excellent absorption. The intramuscular route is a poor choice for diazepam because the absorption is approximately 40% and unreliable.
★ Many COPD patients suffer from hypercapnia and have a low pCO2. Consequently, their drive to breathe is lower and and can be blunted by benzodiazepines. The same can hold for patients with sleep apnea. The benzodiazepines that worsen things the most are diazepam and chlordiazepoxide. One can administer lorazepam with caution.
Buspirone
Cough. Cough. At Psycheteria, buspirone is not a highly respected medication. It does have some use in older adults in low doses, partially because of its lack of side effects. However, in addition to lacking side effects, it lacks all that efficacy too. Regardless, it may work for some people, but because of its activity at 5HT1a it can cause serotonin syndrome when administered with MAOI's.
Antidepressants
For anxiety disorders that are not short-lived, SSRI's are the treatment of choice. Good choices for the medically ill patient, in no particular order, are:
Venlafaxine, which is dose-dependent SSRI/SNRI, is approved for use in Generalized Anxiety Disorder. Venlafaxine is effective, but in medically ill patients, the initial nausea and vomiting may not be well tolerated. Venlafaxine is usually started at 37.5 mg twice daily and titrated upwards.
Paroxetine is approved for the treatment of Generalized Anxiety Disorder as well, but is often associated with weight gain, sexual dysfunction, and somnolence. Sometimes people don't like those side effects. If you use paroxetine, you can start at 10 mg and go upwards.
Antipsychotics
Antipsychotics have various uses in the treatment of anxiety, especially when benzodiazepines are unsuitable (e.g., older frail patients, or patients with COPD). Low doses of haloperidol (0.5-2 mg) can help in the evening or before a stressful procedure, but the anxiety should be extreme. Conveniently, haloperidol can be administered intravenously.
The increasing indications of second-generation antipsychotics is enticing, of course. The use of quetiapine for anxiety is becoming more frequent (usually 25-50 mg bid, with an additional 25-50 mg q 4h prn), but economics should be factored in. It is much more economical to give hydroxyzine 25-50 mg than quetiapine 25 mg. (The same goes for hypnotics. Temazepam is far more economical than quetiapine and should not be rejected because it is a benzodiazepine). Antipsychotics can be useful in anxiety disorders associated with steroids.
Beta-blockers
Beta-blockers help with anxiety by blunting autonomic arousal. They are best for specific anxiety-producing situations as opposed to treatment of panic disorder, for example. Of course, beta-blockers are contraindicated in patients with asthma or COPD.
Antihistamines
Antihistamines can be surprisingly effective in treating anxiety. For example, hydroxyzine (25-50 mg q 4-6 h) has been show to be as effective as benzodiazepines. Diphenhydramine (50-200 mg hs) is a reasonable alternative to benzodiazepines for insomnia. Bear in mind that older patients may be especially sensitive to other side effects such as dizziness.
Anticonvulsants
Anticonvulsants are not usually used to treat anxiety but can be helpful. The efficacy of gabapentin in anxiety (and in seizure disorders) is debatable, though it has few side effects. In patients with dementia or brain injury, divalproex is a reasonable choice and can help with anxiety, behavioral outbursts, and seizure prophylaxis. Some people feel that gabapentin is beneficial too and it has few if any side effects and is excreted renally.
Communication
It is important for the consulation team to communicate with the medical/surgical team regarding the treatment and etiology of anxiety. Anxiety results from the unknown, so it can be beneficial in many cases to facilitate communication between the patient and the primary treatment team to improve understanding.
Psychotherapy
★We are fortunate at UCLA that the C&L team includes a psychologist who can provide ongoing therapy during hospitalization. Supportive psychotherapy can be extremely helpful with anxiety disorders. Usually, cognitive behavioral therapy or insight-oriented therapy is not realistic within the time of contemporary hospitalization.