Update on Pharmacotherapies for PTSD Michelle Pent, MD, MPH April 29, 2011.
-
Upload
karen-ford -
Category
Documents
-
view
213 -
download
0
Transcript of Update on Pharmacotherapies for PTSD Michelle Pent, MD, MPH April 29, 2011.
Update on Update on Pharmacotherapies for PTSDPharmacotherapies for PTSD
Michelle Pent, MD, MPHMichelle Pent, MD, MPH
April 29, 2011April 29, 2011
PresentationPresentation
• Anxiety-spectrum disorder
• DSM-IV criteria– A: Exposure to traumatic event with perceive
threat to life or physical integrity and response of intense fear
– B: Re-experience of the traumatic event– C: Avoidance of stimuli associated with the
trauma– D: Hyperarousal
Target SymptomsTarget Symptoms
• Intrusive ruminations
• Nightmares
• Flashbacks
• Hyperarousal
• Hypervigilance
• Associated irritability, anger, poor focus and concentration, and physiologic distress
NeurochemistryNeurochemistry
• Amygdala
• Central Nervous System– Norepinephrine, Serotonin, Dopamine, GABA
• Peripheral Nervous System– Sympathetic Nervous System– “Fight or flight”
TreatmentTreatment
• Psychotherapy
• Pharmacotherapy
• Most evidence suggests psychotherapy is most effective– CBT– EMDR– DBT where indicated
Complimentary TreatmentsComplimentary Treatments
• Yoga/Meditation
• Acupuncture
• Mindfulness Training
• Relaxation Therapy
PharmacotherapyPharmacotherapy
• Objective is to improve symptoms by minimizing anxiety– Selective Serotonin Reuptake Inhibitors– Other antidepressants– Anxiolytics– Other
Selective Serotonin Reuptake Selective Serotonin Reuptake Inhibitors (SSRIs)Inhibitors (SSRIs)
• Raise serotonin levels in the brain
• Remain standard of care for anxiety disorders
• Linked with– Improvement in baseline level of anxiety– Diminished intrusive ruminations
SSRIsSSRIs
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
SSRIsSSRIs
• Lag time before efficacy– Usually 4-6 weeks– Adequate trial a minimum of 8 weeks
• Side effects– Nausea, diarrhea– Weight gain– Agitation– Sexual dysfunction
Other AntidepressantsOther Antidepressants
• Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)– Venlafaxine (Effexor)– Duloxetine (Cymbalta)– Desvenlafaxine (Pristiq)
• Tricyclic Antidepressants– Amitryptyline (Elavil)– Doxepin (Sinequan)
AnxiolyticsAnxiolytics
• Benzodiazepines
• Alpha adrenergic antagonists
• Buspirone
• Antihistamines
BenzodiazepinesBenzodiazepines
• Diminish anxiety by enhancing GABA in the central nervous system
• No longitudinal effect on anxiety• Significant tolerance and dependence
– Essentially contraindicated in patients with history of substance abuse
• Intended for short term use• Increasingly considered inappropriate for
long term treatment of anxiety disorders
BenzodiazepinesBenzodiazepines
• Diazepam (Valium)
• Lorazepam (Ativan)
• Alprazolam (Xanax)
• Clonazepam (Klonopin)
• Oxazepam (Serax)
• Chlordiazepoxide (Librium)
• Temazepam (Restoril)
Other AnxiolyticsOther Anxiolytics
• Buspirone (Buspar)– Serotonin agent– May cause headache, nausea
• Antihistamines– Diphenhydramine (Benadryl)– Hydroxyzine (Vistaril)– Side effects include sedation, confusion at
high doses
Other AnxiolyticsOther Anxiolytics
• Alpha adrenergic antagonists– Blood pressure medications– Prazosin (Minipress)– Clonidine (Catapres)– Side effects include dizziness and other
complications of low blood pressure
Other AnxiolyticsOther Anxiolytics
• Gabapentin– Anticonvulsant/Mood Stabilizer– Enhances GABA in central nervous system– Some usefulness for anxiety– Limited addictive potential
Use of AntipsychoticsUse of Antipsychotics
• May be useful as anxiolytics
• Use does not necessarily imply psychosis
• Significant sedation, weight gain, metabolic disturbance
• Most commonly used– Quetiapine (Seroquel)– Olanzapine (Zyprexa)– Ziprasidone (Geodon)
SleepSleep
• Benzodiazepine analogues– Eszopiclone (Lunesta)– Zolpidem (Ambien)– Addictive potential
• Benzodiazepines– Short term use
SleepSleep
• Trazodone (Desyrel)– Often exacerbates nightmares
• Mirtazapine (Remeron)– Associated with weight gain
• Melatonin– Ramelteon (Rozerem)