Drugs used in anxiety and panic disorders

1
Drugs used in anxiety and panic disorders

• Prof. Hanan Hagar
• Pharmacology Unit
• College of Medicine

2

• Objectives
• By the end of this lecture you will be able to
• Define different types of anxiety disorders
• Classify types of drugs used for treatment of
  anxiety
• Recognize the different characteristics of
  anti-anxiety drugs

3
Antianxiety drugs

• Drugs that can relieve anxiety without
  interfering with mental or physical function.

4
What is anxiety ?

• Physical and emotional distress which
  interferes with normal life.

5

• Symptoms of anxiety
• Emotional or psychic symptoms.
• Physical or somatic symptoms.

6

• Emotional Symptoms of anxiety
• Irrational and excessive fear and worry
• Irritability
• Restlessness
• Trouble concentrating
• Feeling tense

7

• Physical Symptoms of Anxiety
• Sweating
• Tachycardia
• Shortness of breath
• Stomach upset
• Frequent urination or diarrhea
• Sleep disturbances (Insomnia)
• Fatigue

8

• Types of anxiety
• Generalized anxiety disorder
• Post-traumatic stress disorder (PTSD).
• Obsessive-compulsive disorder (OCD).
• Panic disorder
• Phobia

9

• Generalized Anxiety Disorder (GAD)
• Patients are usually and constantly worried
• about health, money, work with no apparent
• reasons.

10

• Obsessive-Compulsive Disorder (OCD)
• An anxiety disorder in which people cannot
  prevent themselves from unwanted thoughts or
  behaviours that seem impossible to stop as
• Washing their hands

11

• Panic disorder
• An disorder in which people have sudden and
  intense attacks of anxiety in certain situations.
  

12

• Post-traumatic stress disorder (PTSD)
• An anxiety disorder that affects people who have
  experienced a severe emotional trauma, such as
  rape or dramatic car accident, or even war.

13

• Phobia
• An intense, uncontrolled fear of a specific
  situation such as
• open spaces heights

14
Treatment of anxiety

• Psychotherapy (cognitive behavioral therapy).
• Anxiolytics

15

• Classification of anxiolytic drugs
• Benzodiazepines ( BDZ ).
• 5HT1A agonists.
• 5HT reuptake inhibitors.
• Antidepressants
• Beta-adrenergic blockers
• MAO inhibitors

16
Benzodiazepines
17

• Nomenclature of Benzodiazepines
• Have the suffix zolam or zepam

Lorazepam Oxazepam Temazepam Diazepam
Flurazepam
Alprazolam Estazolam Triazolam
18

• Classifications of Benzodiazepines
• are classified according to duration of action
  into
• Short acting(3-8 hours) triazolam- Oxazepam
• Intermediate(10-20 hours) ALET
• Alprazolam - Lorazepam
• Estazolam - Temazepam
• Long acting ( 24-72 hours)
• Chlordiazepoxide -Diazepam -Flurazepam

19
(No Transcript)
20

• Mechanism of Action
• Benzodiazepines act by binding to BZ receptors
• in the brain ? enhance GABA action on brain ?
  chloride channels opening ? ? chloride influx
  to the cell ? hyper- polarization ? reduction of
  neural excitability.

GABA (?-aminobutyric acid) is an inhibitory
neurotransmitter
21
(No Transcript)
22

• Pharmacokinetics
• are lipid soluble
• well absorbed orally,
• can be given parenterally
• Chlordiazepoxide- Diazepam (IV only NOT IM)
• widely distributed.
• cross placental barrier (Fetal depression).
• excreted in milk (neonatal depression).
• metabolized in the liver to active metabolites
  (long duration of action- cumulative effect).

23

• Pharmacological Actions
• Anxiolytic action.
• Depression of cognitive and psychomotor function
• Sedative hypnotic actions
• Anterograde amnesia
• Minimal depressant effects on
• cardiovascular system
• respiratory system
• Some have anticonvulsant effect
• clonazepam, diazepam.

24

• Therapeutic Uses of Benzodiazepines
• Anxiety disorders  
• short term relief of severe anxiety
• General anxiety disorder
• Obsessive compulsive disorder
• Panic attack with depression Alprazolam
• (antidepressant effect)
• Sleep disorders (Insomnia).
• Triazolam, Lorazepam, Flurazepam

25

• Therapeutic Uses
• Treatment of epilepsy
• Diazepam Lorazepam
• In anesthesia
• Pre-anesthetic medication (diazepam).
• Induction of anesthesia (Midazolam, IV)

26

• Adverse Effects
• Ataxia (motor incoordination)
• Cognitive impairment.
• Hangover (drowsiness, confusion)
• Tolerance dependence
• Risk of withdrawal symptoms (rebound insomnia,
  anorexia, anxiety, agitation, tremors
  convulsion).
• Respiratory cardiovascular depression in large
  doses only (toxic effects).

27

• Drug interactions

Drugs Examples
CNS depressants Alcohol antihistaminics effect of benzodiazepines
Cytochrome P450 inhibitors Cimetidine erythromycin t ½ of benzodiazepines
CYT P450 inducers Phenytoin rifampicin t 1/2 of benzodiazepines
28

• Precautions
• pregnant women or breast-feeding.
• Liver disease
• Old people.
• Dose reduction is recommended.

29

• 5HT1A agonists
• Buspirone
• acts as agonist at brain 5HT1A receptors
• rapidly absorbed orally.
• Slow onset of action (delayed effect)
• T½ (2 4 h).

30

• Buspirone
• Only anxiolytic
• No hypnotic effect.
• Not muscle relaxant.
• Not anticonvulsant.
• No potentiation of other CNS
• depressants.
• Minimal psychomotor and
• cognitive dysfunctions.
• Does not affect driving skills.
• Minimal risk of dependence.
• No withdrawal signs.

31

• Uses of buspirone
• As anxiolytic in mild anxiety generalized
  anxiety disorders.

32

• Disadvantages of buspirone
• Slow onset of action (delayed effect)
• GIT upset, dizziness, drowsiness
• Not effective in severe anxiety/panic disorders
• Drug interactions with CYT P450 inducers
• and inhibitors

33

• Beta Blockers
• Drugs as Propranolol atenolol
• act by blocking peripheral sympathetic system.
• Reduce somatic symptoms of anxiety.
• Decrease BP slow HR.
• Used in performance anxiety.
• are less effective for other forms of anxiety
• should be used with caution in asthma, cardiac
  failure, peripheral vascular disorders

34
(No Transcript)
35

• Tricyclic Antidepressants
• Doxepin- imipramine
• act by reducing uptake of 5HT NA.
• Used for anxiety especially associated with
• depression.
• Effective for panic attacks.
• Delayed onset of action (weeks).

36

• Side effects of tricyclic antidepressants
• Atropine like actions
• (dry mouth-blurred vision, tachycardia).
• a-blocking activity (Postural hypotension).
• Sexual dysfunction.
• Weight gain.

37

• Selective serotonin reuptake inhibitors (SSRIs)
• Fluoxetine
• acts by blocking uptake of 5HT
• Orally
• Delayed onset of action (weeks).
• Long half life
• Used for panic disorder OCD depression-
• Generalized anxiety disorders - phobia.

38

• Side effects of SSRIs
• Nausea, diarrhea
• Weight gain
• Sexual dysfunction
• Dry mouth
• Seizures
• Sleep disturbance

39

• Monoamine oxidase inhibitors (MAOIs)
• Phenelzine
• act by blocking the action of MAO enzymes.
• Used for panic attacks and phobia.
• Require dietary restriction
• Avoid wine, beer, fermented foods as old cheese
  that contain tyramine.
• Side effects
• Dry mouth, constipation, diarrhea, restlessness,
• dizziness.

40

• Conclusion of anxiolytics

CLASSES OF ANXIOLYTICS USES
Benzodiazepines Generalized anxiety disorders, OCD, phobia, panic attack
SSRIs (Fluoxetine) Generalized anxiety disorders, OCD, phobia, panic attack
Tricyclic antidepressants (doxepin, imipramine ) anxiety with depression panic attacks
5HT1A agonists (Buspirone) Mild anxiety Not effective in panic attack
Beta blockers (propranolol, atenolol) Phobia (social Phobia)
41

• Conclusion of anxiolytics

CLASSES OF ANXIOLYTICS Adverse effects
Benzodiazepines Ataxia, confusion, dependence, tolerance, withdrawal symptoms,
SSRIs (Fluoxetine) Sexual dysfunction atropine like actions
Tricyclic antidepressants (doxepin, imipramine ) weight gain, sexual dysfunction, atropine like actions, arrythmia
5HT1A agonists (Buspirone) Minimal adverse effects
Beta blockers (propranolol, atenolol) Hypotension