PG11 Anxiety Spectrum and Related Disorders - Devon Partnership ...

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Pharmacological Treatment of Anxiety Spectrum and Related DisordersThe aim of these guidelines is to promote evidenced based, cost effective prescribing for the followingdisorders:Generalised Anxiety disorderPanic disorderPost-traumatic stress disorderSocial anxiety disorder (or social phobia)and support adherence to:NICE CG 113 (Anxiety and panic disorder) 2011NICE CG 26 (Post Traumatic Stress Disorder)NICE CG26 PTSD Evidence Update (2013)NICE CG159 (Social Anxiety Disorder) 2013British Association for Psychopharmacology Guidelines for the treatment of anxiety disordersIf the individual has a depressive illness with anxiety symptoms then please follow theguideline for the pharmacological treatment of unipolar depression.If an individual presents with PTSD and depression, consider treating the PTSD first unlessseverity of depression prevents individual from engaging with psychological treatmentindicated for PTSDThe guidelines are NOT intended to replace prescribing information contained in the BNF or SpecificSummaries of Product Characteristics.Psychological therapies are integral to the successful treatment of these disorders and must beused in preference to drug treatment, but are beyond the scope of these guidelines.For the treatment of anxiety during pregnancy or breast-feeding, please see the Trust PrescribingGuideline on the Pharmacological Management of Perinatal Mental Health Conditions (PG18). Clickhere to access.General Prescribing PrinciplesPharmacological treatment in adults should be considered if:preference for medication expressed by the individualpsychological therapies are not available within an appropriate time frame or where theyhave not resulted in positive outcome for the individual.Suicide risk (from NICE CG113)For people aged under 30 who are offered an SSRI or SNRI:warn them that these drugs are associated with an increased risk of suicidal thinking andself-harm in a minority of people under 30 andsee them within 1 week of first prescribing andmonitor the risk of suicidal thinking and self-harm weekly for the first month.PG11 – Pharmacological Treatment of Anxiety Spectrum & Related DisordersApproved by Drug and Therapeutics Committee: June 2014Review date: June 2016 Page 2 of 13
General advice on use of antidepressants (for anxiety spectrum disorders)At the time that treatment (with an antidepressant) is offered for the management of anxiety disorders,advise patients of:o why the medicine is being prescribed and what the likely benefits of it are going to beo potential side effects (including transient increase in anxiety at the start of treatment)o the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in someinstances if a dose is missed or the dose of the drug is reducedo the delay in onset of effect, the time course of treatment and the need to take medication asprescribed.When starting someone on an antidepressant they should be reviewed 2-4 weeks after startingtreatment and regularly thereafter depending on their response to treatmentBefore prescribing consider the individual’s age, previous treatment responses, risk of self-harm,possible interactions with pre-existing conditions and medicines, the individual’s preference and, whereall else is equal, cost.Side effects on the initiation of antidepressants may be minimised by starting at a low dose andincreasing the dose slowly until a satisfactory therapeutic response is achieved.Actively ask about side effects such as akathisia, increased anxiety and agitation and suicidal ideation.Provide appropriate support where necessary. Review prescribed medication if akathisia is markedand/ or prolonged.In some instances, doses at the upper end of the indicated dose range may be necessary and shouldbe offered if needed (refer to BNF/ SPC product information).Remember: The absence of a licensed indication does not necessarily mean an absence of evidencefor the proposed treatment intervention: conversely it should not be assumed that all drugs within aclass are likely to be efficacious in the treatment of a particular anxiety disorder, when one member ofthat class has proven efficacy (BAP, 2014).Antidepressants in special groupsRefer to Prescribing guideline PG03 for Unipolar depressionWhen prescribing an SSRI, take into account the increased risk of bleeding associated with thismedication, particularly for older people or people taking other drugs that can damage thegastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribinga gastro-protective drug in these circumstances.Stopping antidepressantsWhen stopping an antidepressant, gradually reduce the dose, normally over a 4-week period. This is tominimise the risk of discontinuation effects. Some people may require longer periods, particularly withdrugs with a shorter half-life (e.g. paroxetine).The most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness andtingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxietyand sleep disturbances.If discontinuation/ withdrawal symptoms occur, but are mild; provide reassurance and monitor. Ifsymptoms are severe, consider re-introducing original antidepressant (or another with a longer half lifefrom the same class) and reduce dose more gradually whilst monitoring symptoms.General switching advice for antidepressantsRefer to Prescribing Guideline PG03 for Unipolar depressionChange to prescribing guidance for citalopram and escitalopram:Following MHRA updates in 2011 the maximum dose of these medicines was altered for specificpopulations. This was prompted by a finding of an increased risk of QT interval prolongation which isdose related. Two safety briefings have been issued addressing the safe management of this and areavailable here (11-009 and 11-010).PG11 – Pharmacological Treatment of Anxiety Spectrum & Related DisordersApproved by Drug and Therapeutics Committee: June 2014Review date: June 2016 Page 3 of 13
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