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

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Decision Aid for Specialist Treatment Strategies: Panic DisorderIntervention Comments Approved foruse in DPT?Escitalopram No compelling clinical evidence published to demonstrate N*superiority over citalopram for treatment of panicdisorder, although prescribing costs significantly higher.Fluoxetine Unlicensed indicationYOnly consider if licensed treatment intolerable ofineffectiveKeep initial doses very low (2.5-5mg)Gabapentin Insufficient (and equivocal) evidence to support efficacy NAdditional studies neededImipramine Consider (as an alternative to clomipramine) if insufficient Yor no clinical response achieved with SSRI (at adequatedose and duration)Mirtazapine Unlicensed indicationOnly consider if licensed treatment intolerable ofineffectiveYParoxetine Licensed for the treatment Panic disorder (40mg/ day), YInitial dose 10 mg/day, gradually increased in 10 mgsteps according to response-up to the recommendeddose. Low starting dose recommended to minimise thepotential worsening of panic symptomatology, which isgenerally recognised to occur early in the treatment ofthis disorder.Associated with a higher risk of discontinuation(withdrawal) symptoms following a dose reduction/discontinuation of treatment.Phenelzine Unlicensed indicationYLimited evidence, may be appropriate to consider it insevere/ treatment resistant cases.Valproate Unlicensed indicationYLimited evidence (weak)- may be appropriate to considerit in severe/ treatment resistant cases.(NB. Majority of recently published evidence includesindividuals with concurrent bipolar disorder)Venlafaxine Unlicensed indicationYOnly consider if licensed treatment intolerable ofineffectiveMore commonly associated with discontinuation reactionWhere a prescriber believes it clinically appropriate to consider treatment fora named individual with a non-approved drug, Trust SOP MM26 must be followed.References (Panic disorder)Batelaan NM, Van Balkom AJLM and Stein DJ (2012) Evidence-based pharmacotherapy of panic disorder: Anupdate. Int J Neuropsychopharmacol 15: 403–415.Mula M, Pini S, Cassano G. 2007. The role of anticonvulsant drugs in anxiety disorders: A critical review of theevidence. Journal of Psychopharmacology 27(3): 263-272PG11 – Pharmacological Treatment of Anxiety Spectrum & Related DisordersApproved by Drug and Therapeutics Committee: June 2014Review date: June 2016 Page 8 of 13
Post-Traumatic Stress Disorder - Treatment Choice and DurationShort term use of hypnotic medication may be appropriate for management of sleep disturbance (referto prescribing guidelines for insomnia), but consider use of suitable antidepressant at an early stage forlonger term management.Trauma focused psychological therapy should always be offered as first line treatment, howeverpharmacotherapy should be considered;Where an individual expresses a preference for medication instead of psychological therapyTo augment trauma-focused psychological therapy for individuals who have no or limitedimprovement from psychological therapy aloneFor individuals who cannot start a psychological therapy because of serious on-going threat offurther traumaPharmacological treatment should also be considered as an adjunct to psychological therapy wherethere is significant comorbid depression or severe hyperarousal that significantly affects the ability of anindividual to benefit from psychological treatment.Offer the individual a choice of treatment from the following:Sertraline initially 25mg dailyFluoxetine +Venlafaxine +Mirtazapine + initially 15mg daily at night+ Off-label indication –recommended by NICE CG26/ NICE Evidence update 49)If clinical response to first treatment inadequate (and increasing the dose has not resulted inimproved response) or individual unable to tolerate treatment, change to a different class ofantidepressant (above) or a treatment strategy from specialist decision aid.Notes1. Consider using a short course (maximum 2 weeks) of a benzodiazepine if an individual developsside effects such as acute anxiety, insomnia or agitation upon commencing an antidepressant(especially an SSRI). Bear in mind their risk of falls and avoid if chronic anxiety is present prior tocommencing antidepressant or if they have a previous history of chemical addictive problems.2. If an individual with PTSD develops marked and/ or prolonged akathisia whilst taking anantidepressant drug, treatment should be reviewed.3. Citalopram has NOT been shown to be efficacious for the management of PTSD in placebocontrolled studies.4. Fluoxetine or paroxetine may be preferable option for improving depressive symptoms for adultswith PTSD and concurrent depression (EHCP,2013)5. Fluoxetine may be preferable option if symptoms of anxiety are prominent for adults with PTSD(EHCP,2013)6. Doses of regularly prescribed medication should not be omitted if an individual is receiving eyemovement desensitisation and reprocessing (EMDR) therapy. There is no evidence to indicate thatpsychotropic medication will impact on the effectiveness of EMDR.PG11 – Pharmacological Treatment of Anxiety Spectrum & Related DisordersApproved by Drug and Therapeutics Committee: June 2014Review date: June 2016 Page 9 of 13
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