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Saturday, March 24 - Handling Anxiety without Benzodiazepines


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Handling Anxiety without Benzodiazepines
0006-0000-18-005-L01-P | .1 CEU | Kimberly Hoffman, PharmD, BCPP, BCGP

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Saturday, March 24 - Handling Anxiety without Benzodiazepines

  1. 1. Handling Anxiety Without Benzodiazepines Kimberly A. Hoffmann PharmD, BCPP, BCGP Clinical Professor of Pharmacy Practice Thomas J. Long School of Pharmacy and Health Sciences at the University of the Pacific Stockton, California or
  2. 2. There are no direct conflicts of interest relating to the contents of this work. This presentation was not commissioned, funded or sponsored by any pharmaceutical company or other financial enterprise
  3. 3. Goals of this Presentation:  This presentation will provide the participant with an overview of anxiety including the neurotransmitters that are influencing the symptoms of anxiety disorders and being manipulated in current treatment regimens.  This program will familiarize the participant with non-pharmacologic strategies to employ in the treatment of anxiety.  This presentation will update the participant with the newest pharmacologic approaches to treat anxiety while avoiding the used of
  4. 4. OBJECTIVES 1. Identify the symptoms, causes, and consequences of anxiety. 2. Articulate the differences between complementary, alternative, integrative and traditional medications. 3. Recognize new strategies for alleviating anxiety utilizing methods other than traditional medications. 4. Describe updated pharmacologic medications that can be utilized for anxiety After attending this presentation, participants should be able to:
  6. 6. What is an Anxiety Disorder?  Anxiety is a normal emotion under circumstances of threat and is thought to be part of the “fight or flight” reaction to survival. It is a natural protective mechanism for human beings to act as a warning of impending danger.  An anxiety disorder maintains some form of anxiety or fear coupled with worry.  The fear portion of anxiety, is centered out of the amygdala, which is an almond-shaped brain center located near the hippocampus that has connections that integrate sensory and cognitive information. This determine whether there will be a fear response.  Worry is linked to an area of the brain called the cortico- striatal-thalamo-cortical (CSTC) loops or circuit.
  7. 7. Types of Anxiety Disorders: • Anxiety disorders are the most common types of mental health disorders in America¹ • The five most common anxiety disorders are:² • Generalized Anxiety Disorder. (GAD) • Obsessive-Compulsive Disorder (OCD) • Panic Disorder (PD) • Post-Traumatic Stress Disorder (PTSD) • Social Phobia (or Social Anxiety Disorder) • 1. • ².
  8. 8. Causes of Anxiety Disorders In humans, fear is learned during stressful experiences associated with emotional trauma and is influenced by genetic predisposition. When a human being is in a truly dangerous situation, it is crucial that he is fearful to survive. This is the mechanism of learned fear, called fear conditioning. Often the fear is overwhelming and cannot be forgotten as in Post Traumatic Stress Disorder. The locus ceruleus in the brain becomes overly sensitive, and the person experiences hyperarousal and re- experiencing of events. This is a result of
  9. 9. Causes of Anxiety (con’t)  Panic associated with social situations will “teach” a patient to panic when he/she gets into a similar social situation resulting in Social Anxiety Disorder. The hippocampus of the brain remembers the context of the fear conditioning and makes sure fear is triggered when the fearful stimulus and all of its associated stimuli are encountered.
  10. 10. Fear Extinction  Fear extinction is the progressive reduction of the response to a feared stimulus and occurs when the stimulus is repeatedly presented without any adverse consequence.  In psychology they use the technique called “Exposure Therapy” to rid people of their fears, phobias, and anxiety. Fear is overcome, but never forgotten. The fear response is modified. Inhibitory GABAergic drive overcomes excitatory Glutamatergic drive.
  11. 11. Child Abuse and Early Exposure to Stress  Overwhelming early life stress such as physical, emotional or sexual abuse can cause a serious condition known as stress sensitization. Sustained and repeated stressors from emotional trauma not only lead to activation of brain circuits while the stressor is being experienced, but may cause the circuit to be irreversibly activated even when the stressor is withdrawn. Often a child will show no signs of distress or mental illness at the time of the early life exposure to abusive stressors. When the individual is exposed to multiple stressors later in adulthood, the circuits decompensate and the patient develops an anxiety disorder or a major depressive episode.
  12. 12. Worry  Worry may include anxious misery, apprehensive expectations, catastrophic thinking, and obsessions.  Worry is linked to the cortico-striatal-thalamic-cortical feedback loops in the prefrontal cortex.  It is thought that catechol-o-methyl-transferase (COMT) regulates the availability of the neurotransmitter dopamine in the prefrontal cortex.  With different genetic variants of COMT, lesser amounts of COMT may be active and with increased exposure to stressors, resulting in excessive dopamine release and causes symptoms of worry and obsessions. This is thought to be one mechanism contributing to Obsessive Compulsive Anxiety Disorder.
  13. 13. Gamma-aminobutyric acid (GABA) and Anxiety The amino acid glutamate, a precursor to GABA, is converted to GABA by the enzyme glutamic acid decarboxylase (GAD). After synthesis, GABA is transported into synaptic vesicles via vesicular inhibitory amino acid transporters (VIAATs) and stored until its release into the synapse during neurotransmission. GABA is the principal inhibitory neurotransmitter in the brain and serves an important role in reducing the activity of many excitatory neurons, including those in the amygdala and in the CSTC loops. GABA’s synaptic actions are terminated by the presynaptic GABA transporter (GAT) or by the enzyme GABA transaminase (GABA-T) . Sub-types of GABA-A receptors are the targets of benzodiazepines, barbiturates, and alcohol.
  14. 14. Serotonin and Anxiety Serotonin is a key neurotransmitter that innervates the amygdala, and antidepressants that increase serotonin output by blocking the serotonin transporter (SERT) are also effective in reducing symptoms of anxiety and fear in all of the five main anxiety disorders. A serotonin 1A partial agonist (buspirone) works as a generalized anxiolytic that usually works adjunctively as augmenting agents to the antidepressants. This is also the mechanism used in atypical antipsychotics that help to calm anxiety. There is also some anxiolytic actions that occur with pre and postsynaptic 5HT1A
  15. 15. Serotonin and Anxiety (con’t) Serotonin is involved in the therapeutic action of numerous anxiolytics for anxiety disorders, but it also plays a role in regulating the efficiency of information processing in the amygdala. This results in vulnerability or resilience of fear circuits. This is hereditary. SERT s or l, the type of transporter you are born with, may determine if your amygdala overreacts when you see people expressing fear. It may also determine how well you respond to stress and if your brain atrophies (hippocampal atrophy) with exposure to chronic stress. It is also thought to be an important factor in whether your anxiety disorder responds well to an SSRI or SNRI. The s variant is much more vulnerable to anxiety disorders.
  16. 16. Glutamate and Anxiety Glutamate is an anion of the amino acid glutamic acid and serves as a key excitatory neurotransmitter in the CNS and as a precursor to the inhibitory neurotransmitter GABA, in addition to its central roles in protein synthesis and metabolism. The two principal families of glutamate receptors are ionotropic and metabotropic receptors. NMDA is one of these ionotropic receptors. Glutamate is thought to play a large role in anxiety, but it is toxic when produced in large amounts, and regulation of glutamate has been very difficult for medical research.
  17. 17. Norepinephrine and Anxiety Norepinephrine is another neurotransmitter with important regulatory input into the amygdala and to many regions to which the amygdala projects. Excessive noradrenergic output from the locus ceruleus can result in sympathetic over activity. This may trigger numerous symptoms of anxiety and fear such as: nightmares, hyperarousal, sweating, tachycardia, tremors, and panic attacks.¹  This may affect alpha -1 and beta-1 adrenergic receptors in the amygdala also.  Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) will sometimes worsen anxiety and SSRIs are often preferred for patients with extreme anxiety over the SNRIs. 1. Stahl, S.M., Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, 3rd edition; 2008 pg. 757
  18. 18. Common Symptoms of Anxiety  Panic, fear, and uneasiness.  Sleep problems.  Not being able to stay calm and still.  Cold, sweaty, numb or tingling hands or feet.  Shortness of breath.  Heart palpitations.  Dry mouth.  Nausea.
  19. 19. Consequences of Sustained Anxiety Persistently elevated glucocorticoids may damage the hippocampus and promote atrophy and also prevent it from inhibiting the HPA axis, thus resulting in disinhibition of the HPA axis and chronic elevation of all HPA stress hormones which overtime would most likely result in an anxiety disorder or major depressive episode. Hypertension Weight gain (carbohydrates promote serotonin secretion)  Substance abuse (both illicit and prescription drugs, and alcohol abuse which may lead to liver disease etc..  Decreased Quality of Life and little happiness experienced.
  20. 20. Complementary or Alternative?  Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. • Please note that most of the CAM therapies are not under the auspices of the approval process of the United States Food and Drug Administration (FDA). • Most of the information has been obtained from National Center for Complementary and Alternative Medicine, a division of the National Institute of Health (NIH). • accessed 2-2-18
  21. 21. Examples • Complementary medicine is used together with conventional medicine. Aromatherapy: scent of essential oils from flowers, herbs and trees is inhaled to promote health and well-being to help lessen a patient's discomfort following surgery. • Alternative medicine is used in place of conventional medicine, i.e. following a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor. • Integrative medicine is an approach to medicine that combines treatments from conventional medicine and CAM for which there is some high-quality scientific evidence of safety and effectiveness, i.e. massage therapy in addition to medications.
  22. 22. Most Common CAM Therapies Used: • Acupuncture* • Ayurveda* • Biofeedback* • Chelation therapy* • Chiropractic or osteopathic manipulation* • Deep breathing exercises • Diet-based therapies • Atkins diet • Macrobiotic diet • Ornish diet • Pritikin diet • South Beach diet • Vegetarian diet • Zone diet • Energy healing • Guided imagery • Homeopathic treatment • Hypnosis* • Massage* • Meditation • Movement therapies • Alexander technique • Feldenkrais • Pilates • Trager psychophysical integration • Natural products (non-vitamin and nonmineral, such as herbs and other products from plants, enzymes, etc.) • Naturopathy* • Progressive relaxation • Qigong • Tai chi • Traditional healers* • Botanica • Curandero • Espiritista • Hierbero or Yerbera • Native American healer/Medicine man • Shaman • Sobador • Yoga
  23. 23. Non-Pharmacologic Advice for Patients Suffering from Anxiety: Get plenty of sleep-teach sleep hygiene Try to figure out the root of the anxiety  Cognitive Behavioral therapy or any type of counseling with a therapist.  Exercise  More exposure to situations that evoke anxiety, this is best performed slowly and in small increments  Breathing exercises-especially when patient is suffering from panic attacks. EMDR: Eye movement desensitization and reprocessing. Must be by a trained clinician. Patient relives the traumatic event.  Hypnosis  Meditation (i.e.Yoga, TaiChi)
  24. 24. Biologically Based Therapy is a Form of Alternative Medicine• Biologically based practices use substances found in nature such as herbs, foods, vitamins and other natural substances. • Some examples of biologically based practices include dietary supplements, herbal products and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark
  25. 25. What Biologically Based Therapies are Commonly Used to Reduce Anxiety?Valerian Root-herb used for thousands of years as a sedative. Causes sedation, but over time may also cause insomnia. There are no natural food sources that contain valerian. Many drug interactions. No studies showing efficacy with anxiety.  Kava Kava-Root found in South Pacific Islands. Used as a tea or supplement powders and tinctures. Makers claim it produces brain wave changes similar to those that diazepam causes. Also claim that it reduces seizures and relaxes muscle. This root causes serious hepatic problems, SOB, Scaly rash, and facial swelling.  L–theanine, an amino acid found in green tea, manufacturers claim it increases the activity of GABA, and also stimulates the release of dopamine
  26. 26. Biologically Based Therapies(con’t)  Gama Aminobutyric—acid (GABA) as a natural supplement  Ashwagandha Root has been used by Indians in health tonics and calming serums. Ashwagandha is an antioxidant that manufacturers claim has a measurable impact on calming anxiety, reducing panic and boosting low mood.  Brahmi (a.k.a. Bacopa Monnieri) is a mild sedative that manufacturers claim supports the body during periods of emotional stress. Traditionally, Brahmi was prescribed to promote healthy cognitive functions, including focus, concentration, mental endurance and memory. Manufacturers also claim that Brahmi's anti anxiety properties are as potent
  27. 27. Biologically Based Therapies(con’t)Tryptophan is a supplement purchased for stress and panic issues. It is an essential amino acid that the body converts into 5—HTP, and then to Serotonin. It is thought to be unsafe: In 1989, a life-threatening condition called eosinophilia-myalgia syndrome (EMS) occurred in many people using tryptophan and some died from the condition. All of these people had taken tryptophan distributed by a company in Japan. This product was found to contain trace levels of impure ingredients. Since that time, the FDA has limited the availability of tryptophan in the U.S. However, the increased use of the Internet has made many dietary supplements
  28. 28. Biologically Based Therapies (con’t) • Patients should be warned to stop using tryptophan and seek emergency medical help if you have signs of EMS: unusual tiredness; severe muscle pain (most often in the shoulders, back, or legs);weakness, numbness, tingling, or burning pain (especially at night);tremors or twitching muscle movements; swelling in any part of your body;skin changes (dryness, yellowing, hardening, rash, hair loss);breathing difficulty; or uneven heartbeat. • Common side effects may include: feeling drowsy or light-headed; dry mouth, heartburn, burping, gas; stomach pain, nausea, vomiting, diarrhea; weakness, lack of coordination; blurred vision; headache; or sexual problems.
  29. 29. Biologically Based Therapies (con’t)  5-HTP (5—hydroxy—tryptophan): In the body, 5-HTP is a precursor to serotonin. There is a lack of research demonstrating efficacy of this supplement. Side Effects of 5-HTP::Diarrhea, nausea, or vomiting, heartburn, gas, or bloating, stomach discomfort or pain, decrease in or lack of appetite, and eosinophilia myalgia syndrome, a condition in which a person may have sudden and severe muscle pain, cramping, trouble breathing, and swelling in the body. Although rare, this
  30. 30. Biologically Based Therapies (con’t)  Passion Flower: A natural remedy for anxiety, chronic stress and insomnia. Makers claim that studies also indicate that Passion Flower can reduce anxiety caused by withdrawal from opiates and other drugs.  Lemon Balm: A small study was conducted in 2014 and showed some efficacy with anxiety. Previous studies suggest that a compound in lemon balm (rosmarinic acid) may have anti- anxiety effects by increasing the availability of GABA (a signaling chemical) in the brain.
  31. 31. Biologically Based Therapies (con’t) Magnesium deficiency is one of the leading causes of frequent nervousness and panic, and the western diet tends to be lacking in this critical element.  Niacin or niacinamide: a type of vitamin B3, works with the body to convert Tryptophan into 5—HTP, which can then be converted into Serotonin. Without B3, Tryptophan–5HTP conversion cannot take place. Common symptoms of B3 deficiency include irritability, poor concentration, anxiety, fatigue, restlessness, apathy, and low mood. Vitamin B Complex: Vitamin B is essential to maintaining proper brain function. Vitamin B is involved in the metabolism, as well as the production of Serotonin. Low levels of Vitamin B have been linked to high stress levels, restlessness, fatigue, irritability, and emotional instability.
  32. 32. Benzodiazepines: what is all the raucous about? National Overdose Deaths—Number of Deaths Involving Benzodiazepines. The figure above is a bar chart showing the total number of U.S. overdose deaths involving benzodiazepines from 2002 to 2015. The chart is overlayed by a line graph showing the number of deaths of females and males. From 2002 to 2015 there was a 4.3-fold increase in the total number of deaths. rates
  33. 33. Pharmacologic Strategies for Treating Anxiety;  People often self-medicate with alcohol, opioids, marijuana, and other illicit drugs.  Historically, before benzodiazepines were created, anxiety was often treated with drugs such as: phenobarbital, amitriptyline, doxepin, and meprobamate.  In 1963, diazepam (Valium™), the first benzodiazepine, was manufactured, and by 1978, it was the first drug to hit over one billion dollars in sales¹  The number of substance abuse treatment admissions reporting both benzodiazepine and narcotic pain reliever abuse increased 569.7 percent from 5,032 admissions in 2000 to 33,701 admissions in 2010, while the number of all other admissions decreased by 9.6 percent during the same period  In the month prior to treatment admission, 57.1 percent of benzodiazepine and narcotic pain reliever combination admissions reported daily use of narcotic pain relievers and 45.5 percent reported daily use of benzodiazepines² 1. 2. use/BenzodiazepineAndNarcoticPainRelieverAbuse/BenzodiazepineAndNarcoticPainReliever Abuse.htm
  34. 34. Should Benzodiazepines (BZDs)be used at all? Benzodiazepines are very effective in many situations, but use in the short- term should be the goal. The following are some useful examples: • Alcohol detoxification • Pre-operative anesthesia • Extreme anxiety with other behavioral interventions such as cognitive behavioral therapy. • Emergency interventions
  35. 35. Alternatives for BZDs in Anxiety Disorders: Selective Serotonin Reuptake Inhibitors (SSRIs)Serotonin is the key neurotransmitter that innervates the amygdala, and it is known that antidepressants that can increase serotonin output by blocking the serotonin transporter (SERT) are also effective in reducing symptoms of anxiety and fear in every one of the five main anxiety disorders.¹  The selective serotonin reuptake inhibitor (SSRI) class of antidepressants is first-line in treating both depression and anxiety disorders. 1. Stahl, S.M., Stahl’s Essential Psychopharmacology: Neuroscientific Basis and rd
  36. 36. Alternatives for BZDs in Anxiety Disorders: Selective Serotonin Reuptake Inhibitors (SSRIs)The selective 5-HT re-uptake inhibitors (SSRIs) are thought to restore the levels of 5-HT in the synaptic cleft by binding at the 5-HT re-uptake transporter preventing the re-uptake and subsequent degradation of 5-HT. This re-uptake blockade leads to the accumulation of 5-HT in the synaptic cleft and the concentration of 5-HT returns to within the normal range.  when SSRIs are initiated, the patient will often experience increased anxiety called “jitteriness syndrome” This uncomfortable side effect will usuallyresolve within 1-2 weeks of therapy. Doses are often initated at ½ strength, increased exercise and limiting caffiene and other stimulants are also useful during this time period. Some prescribers add a small non-refillable dose of a BZD or other
  37. 37. Alternatives for BZDs in Anxiety Disorders (con’t):  Hydroxyzine pamoate : Does cause daytime drowsiness in many, but effective for both anxiety and sleep. Must exercise caution when anticholinergic effects are troublesome as in the elderly due to fall risk, glaucoma patients, asthma patients etc..  Buspirone: Great drug for anxiety. Buspirone is an azapirone that acts as a full agonist on the serotonin 1A (5HT1A) autoreceptor in the limbic system and as a partial agonist on the postsynaptic 5-HT1A receptor in the raphe nuclei. Buspirone also has some mild activity on D2receptors. Patients who are drug-seeking will not want this drug. This must be prescribed as a scheduled dose, not prn. The true effect of this drug is not usually felt for 2-4 weeks after initiation. Buspirone is indicated for anxiety disorders.
  38. 38.  Beta-Blocker use in treating anxiety has increased recently as clinicians are trying to find alternatives to benzodiazepines. Propranolol or Atenolol are the two beta-blockers usually chosen as they penetrate the blood brain barrier. Caution must be exercised as beta blockers have the potential to cause or worsen depression. The beta blockers are effective at treating some somatic symptoms of anxiety such as: sweating, tachycardia, and shaking.  Studies evaluating the antianxiety and anti-panic properties of β-blockers do not support their routine use in treating either generalized anxiety disorder or panic disorder. The use of propranolol for anxiety disorders accompanied by physical symptoms, especially cardiovascular complaints, may be effective in some patients when combined with benzodiazepines or perhaps in some non-responders to conventional treatment.¹ 1. Hayes, P., Schultz, S.Charles, Beta-blockers in anxiety Disorders; Journal of Alternatives for BZDs in Anxiety Disorders: Beta- Blockers
  39. 39. Alternatives for BZDs in Anxiety Disorders: Alpha-2 Agonists  Alpha 2 adrenergic agonists (ie, guanfacine and clonidine) are considered to be alternatives to other anxiety medications based on their ability to modulate noradrenergic tone in the prefrontal cortex.  Fear and anxiety can be produced by electrical stimulation of the locus ceruleus. Anxiety and panic are produced by α2 antagonists, and therefore: α2 agonists such as: clonidine and guanfacine can be anxiolytic  These drugs are sometimes used adjunctively to SSRIs to help patients suffering with anxiety to sleep better, reduce irritability, and produce a more calm
  40. 40. Newer Novel Approaches to Treating Anxiety Disorders:  Gabapentin and pregabalin are alpha 2 delta ligands that bind to the alpha 2 delta subunit of the presynaptic N and P/Q types of voltage-sensitive calcium channels. They are anticonvulsants, and when they bind it blocks the release of excitatory neurotransmitters such as glutamate in some brain regions. It is hypothesized that these drugs may bind in the amygdala and CSTC loops and reduce the activity of overactive anxiety circuits.  Caution must be exercised whenever initiating or titrating down or off of anticonvulsants to avoid seizure or other electrical symptoms sometimes described as a “zapping feeling” in the head.
  41. 41. The Future? A focus on newer strategies for alleviating anxiety disorders is being avidly pursued. Drug research is focusing on glutamate and the NMDA receptor, as well as more precise regulation of other neurotransmitters.  Endocannabinoids show promise in alleviating some aspects of anxiety.  Researchers at McMaster University in Hamilton, Ont. believe there's a strong relationshipbetween the bacteria and microbes that live in our bellies, and the chemistry of our brains.  Many non-pharmacologic strategies are being researched to also help with the symptoms of anxiety.
  42. 42. Case #1: Ms. Lancaster A 23 y.o AA female walks up to your pharmacy counter holding a two prescriptions that were prescribed for her. Her hands are shaking, and she has trouble looking you in the eye while speaking. The prescription reads as follows: 1. Sertraline 50mg tab Take ½ tablet po qam for 10 days then increase to 1 tablet po qam thereafter Qty:25 No refill ___________________________________________________ 2. Lorazepam 0.5mg tablet Take 1 tablet po up to a maximum of tid (q8h) prn extreme anxiety Qty: 20 Non-refillable Question #1: Ms. Lancaster asks you why she is being prescribed two prescriptions, and she is afraid of getting “hooked on medications” She explains that her mother just “passed away” after a long battle with cancer. Ms. Lancaster is visibly distraught and nervous. What do you do? Please choose the one most correct
  43. 43. Case#1 Ms. Lancaster (con’t) A. You call the provider to explain that the lorazepam is not appropriate because the patient’s depression and anxiety will be alleviated by the sertraline. Lorazepam is “overkill” B. You fill the prescription as prescribed and explain to the patient that the lorazepam is a temporary measure to help her get through the first week or two of initiation of sertraline. C. You call the provider and ask him to change the lorazepam to buspirone so that there is no possibility of dependence on the lorazepam. D. You explain to the patient that she probably should not fill the lorazepam as they are dangerous. You explain that the medical community is trying to stop the prescribing of these drugs because they are controlled substances and the overdose rate has escalated tremendously over the last decade due to overuse of these types of drugs.
  44. 44. Case #1: Ms. Lancaster (con’t) Question #2: What other non-pharmacologic strategies could be utilized to combat the jitteriness syndrome Ms. Lancaster may experience and to soothe her anxiety while the sertraline is taking effect?
  45. 45. Case#2 Mr. Cartwright A 70yo Caucasian malodorous male has come into your ambulatory care clinic asking for something to “calm his nerves.” Upon further discussion, he explains that he cannot sleep, he feels nervous all the time, his back hurts and the pain pills he takes don’t work very well anymore. He explains that since his family sold his house and moved him into their home, he doesn’t have much to do, and his anxiety just keeps getting worse. His granddaughter gave him a “zany bar” and he was able to sleep and nothing seemed so bad. He is requesting “that drug.”
  46. 46. Case #2 Mr. Cartwright Question # 1 What do you think is the primary diagnosis is for this patient? A. Substance Dependence B. Generalized anxiety disorder C. Depression with anxiety D. Dementia
  47. 47. Mr. Cartwright (con’t) Question # 2 Is the prescription for alprazolam appropriate for this patient? A. Yes, this is an elderly gentleman in pain. He does not work or drive, and he deserves a better quality of life. B. Yes, it would be ok, but certainly not in a 2mg dose. A 0.5mg or 1mg dose would be more appropriate for an elderly patient. C. No, this patient is likely depressed and needs an anxiolytic that is not as dangerous as alprazolam. D. No, this patient would benefit from hydroyzine pamoate as it is not a controlled substance and has a much better safety
  48. 48. Case # 3 Jennifer Harper  Jennifer is a 22 year old college student who comes into your pharmacy with a prescription from her psychiatrist that reads: Alprazolam 1mg tablet #90 Take 1 tablet up to tid prn panic attacks. Do you fill this prescription? A. Yes, but counsel the patient on the possibility of drug dependence, DUI and try to offer other non- pharmacologic strategies to overcome panic attacks. B. Maybe, but you call the prescriber first to discuss other prescription alternatives for this patient.
  49. 49. QUESTIONS?