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Mary GTop of Form

Generalized Anxiety Disorder

Discussion replay 1

Generalized anxiety disorder (GAD) is one of the commonest anxiety disorders, characterized by excessive and persistent worrying and anxiety about normal day-to-day circumstances such as job security, children’s well-being, health, and so forth (Newman et al.,2017). The DSM-V manual diagnostic criterion for GAD entails the presence of the described symptoms, with worry being the core criterion for most days for six months. There is also difficulty in controlling worry (Newman et al.,2017). For the assignment case study, a 56-year-old presented to the clinic having been referred by his primary care provider. He had earlier gone to the emergency room with symptoms of shortness of breath, chest tightness, and a feeling of impending doom. The tests run at the emergency room ruled out a myocardial infarction; hence he was referred to the psychiatric clinic for further evaluation.

On evaluation, the patient reports a history of alcohol consumption to help deal with his job concerns. The patient also reported consuming 3 to 4 beers in the evening to calm him as he was responsible for caring for his aging parents. Using the Hamilton Rating Anxiety Scale (HAM-A), the patient’s score was 26, indicating severe anxiety (Thompson, 2015). Therefore, history and evaluation indicated that the patient had GAD. This paper seeks to discuss how to evaluate and prescribe medication for clients requiring anxiolytic therapy, pharmacokinetics, and pharmacodynamics to be considered, and how they alter drug response.

Decision Steps based on Patient Factors

The patient was initially begun on 50 mg of Zoloft orally. Zoloft, a Selective Serotonin Reuptake Inhibitor (SSRI), is among the first lines for treating GAD alongside SNRIs, benzodiazepines, α2δ ligands, and buspirone. SSRIs have shown better and faster responses than serotonin-norepinephrine reuptake inhibitors (SNRIs). While imipramine, a tricyclic antidepressant, is also effective as an anxiolytic, it has adverse effects like cardiac arrhythmias, extrapyramidal symptoms, and so forth (Newman et al., 2017). It is also a sedative; hence may worsen sedative effects in someone taking alcohol and even promote suicidal ideation. Buspirone has no immediate anxiolytic effects as it takes 2 to 4 weeks for the onset of action and is typically administered to augment the actions of SSRIs and SNRIs. The client returns to the clinic in four weeks with reduced symptoms and a HAM-A of 18, down from 26. Also, there are no reported side effects.

For the second decision point, I decided to up the dosage of Zoloft to 75 mg since the patient experienced no side effects from the medication. The choice was to increase to 75 and not 100 to monitor response and avoid side effects. The goal was to lower the HAM-A score by lowering his anxiety levels even more. Four weeks later, the client presented a further reduction in anxiety levels with a HAM-A of 10. His symptoms had reduced by 61%. This indicated good response and tolerance to the medication at the prescribed dose.

The client was showing good tolerance and response at 75mg of Zoloft. The decision at this point was to maintain the treatment at the same dose rather than increase and risk causing side effects that might impact adherence. Buspirone would have been added as an augmentation had the patient failed to respond to treatment. The expectation is that in 12 weeks, we would expect further improvement.

Pharmacotherapeutics

Sertraline is an SSRI which means that it blocks the uptake of serotonin at the neuron junction. The neurotransmitter accumulates, facilitating transmission that ensures appropriate emotions and helps reduce anxiety levels. The medication is well tolerated and appropriate, particularly for this individual, given his history of alcohol abuse, as it has no sedative effects.

Factors Influencing Patient’s Pharmacokinetics and Pharmacodynamics

One of the key factors influencing the patient’s pharmacokinetics and pharmacodynamics lies in his history of alcohol consumption. Given sertraline’s actions at the neuron junction to block serotonin receptors, inhibiting uptake hence encouraging the accumulation of serotonin, which is a mood-stabilizing hormone (Newman et al., 2017). Alcohol temporarily increases serotonin levels and hence has the potential to increase CNS side effects of sertraline such as dizziness, poor concentration, and drowsiness. It may also increase the risk of suicidal thoughts and tendencies. Also, studies indicate that males, such as the patient do not respond to psychotropics like sertraline as effectively as women, and hence might require higher doses (Newman et al., 2017).Bottom of Form

Yesenia C

Discussion Reply 2

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Generalized anxiety disorder (GAD) means that you are constantly worrying and cannot control the worrying (Generalized Anxiety Disorder (GAD), 2021). People with GAD worry about things that are unlikely to happen, and excessive worrying can interfere with their daily activities.  Healthcare providers diagnose GAD when your worrying happens most days and for at least six months (Generalized Anxiety Disorder (GAD), 2021). 

            There are several different medications for the treatment of generalized anxiety disorder. Selective serotonin re-uptake inhibitors (SSRIs) are one commonly used treatment. Selective serotonin re-uptake inhibitors are antidepressants that can relieve anxiety symptoms and help reduce the symptoms of depression that are often accompanied (Treatment Options for Generalized Anxiety Disorder, 2017). SSRIs take 2 to 6 weeks for them to start reducing anxiety. The Food and Drug Administration (FDA) approved first-line choices include SRIs, including both SSRIs and SNRIs and busPIRone. The four antidepressants approved for GAD are venlafaxine, DULoxetine, PARoxetine, and  escitalopram. The second-line choices include benzodiazepines. SSRIs block serotonin’s reabsorption into neurons, making more serotonin available to improve the transmission of messages between neurons (Treatment Options for Generalized Anxiety Disorder, 2017). These medications are considered safe and have few side effects that usually go away after the first few weeks and can cause sexual dysfunction or to have less interest in sex (Treatment Options for Generalized Anxiety Disorder, 2017). SNRIs work by effecting changes in the brain chemistry and communication in brain nerve cell circuitry known to regulate mood to help relieve depression. SNRIs are DULoxetine and venlafaxine and are also considered safe to take even though SSRIs have fewer side effects than SNRIs. 

            Benzodiazepines are another medication used to treat GAD. Benzodiazepines are ALPRAZolam, chlordiazePOXIDE, clorazepate, diazePAM, LORazepam, and oxazepam.   Benzodiazepines produce their effects by enhancing the binding of GABA to its receptors (Elgarf et al., 2018). GABA activates the chloride ion channel, allowing chloride ions to enter the neuron and the flow of chloride ions into the neuron hyperpolarizes and inhibits the neuron (Elgarf et al., 2018). Benzodiazepines are effective for the management of anxiety disorders and should be judiciously considered after the screening of relevant risk factors for negative outcomes, including a history of substance abuse, current use of opioids and alcohol, the risk for falls, and cognitive impairment (Tibrewal et al., 2021). Benzodiazepines are usually recommended for the short term, not the long term because they can be addictive. 

            Pharmacokinetics can differ from person to person and is influenced by factors like pathophysiology, genetics, diet, environment, body weight, pregnancy, and drug-drug or food-drug interactions (Pharmacokinetics | AACC.org, n.d.). Body composition disparities between the sexes, including changes in total body water, percentage of body fat, muscle mass, size of organs, blood volume, and flow, as well as metabolism enzymes, will affect pharmacokinetics and, ultimately, the therapeutic effects of the medicine (Pharmacokinetics | AACC.org, n.d.). Genetics may influence drug metabolism, and genetic differences may affect how medications are metabolized in the body. Age has an impact on drug metabolism and elimination as well. Children may eliminate drugs more quickly, while elderly people with impaired kidney, liver, or heart function have slower drug removal. Drug metabolism can be slowed down by illness, infection, and inflammation, which may increase the drug’s half-life and duration of effect (Pharmacokinetics | AACC.org, n.d.). The duration and effectiveness of a medicine’s action can be affected by interactions between foods, drugs, and herbs and by changes in drug metabolism.

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