NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

Sample Answer for NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder Included After Question

Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders. 

Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA approved indications when referring to different medication classes used in the treatment of GAD. 

RESOURCES 

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.  

WEEKLY RESOURCES 

To Prepare: 

  • Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics. 
  • Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug. 
  • Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease. 
  • Think about a personalized plan of care based on these influencing factors and patient history with GAD. 

BY DAY 3 OF WEEK 8 

Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used. 

BY DAY 6 OF WEEK 8 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!  

A Sample Answer For the Assignment: NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

Title: NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

Pharmacokinetics and Pharmacodynamics Anxiolytic Medications for GAD

Anxiety is a type of medical condition whereby the person feels worried, uneasy, nervous, or stressed. According to the American Psychiatric Association, anxiety is defined as an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V) classifies anxiety disorders into several main types such as generalized anxiety disorder, panic anxiety, and selective mutism.

Generalized anxiety disorder (GAD) is a type of anxiety that makes a person feel constantly worried. These worrying feelings are about anything and they can last for more than six months. Other symptoms of GAD include nausea, fatigue, trembling, urinating often, sweating hot flashes, irritability, and trouble breathing (Andrews et al., 2010). People diagnosed with GAD are subjected to psychotherapy and medical treatment. The medications used to treat GAD are classified as anxiolytic medications which are a group of drugs used to prevent or treat anxiety symptoms or disorders. They are sometimes called anti-anxiety medications or minor tranquilizers. Anxiolytic medications are habit-forming and can lead to dependency or a substance use disorder. For this reason, they’re often only prescribed for a short amount of time. Some of the anxiolytic medications include SSRIs (sertraline, fluoxetine, paroxetine, and citalopram). Selective serotonin-norepinephrine reuptake inhibitors (SNRI) such as Venlafaxine and Duloxetine have been approved by FDA as a treatment for GAD. Benzodiazepines (alprazolam) and other types of anxiolytic medications such as Second-generation antipsychotics (SGAs).

Before prescribing these drugs to any patient, it is important to understand their pharmacokinetics and pharmacodynamics. For example, the pharmacokinetics and pharmacodynamics of benzodiazepines involve the increase of g-aminobutyric acid (GABA) inhibitory impulses in the central nervous system mediated via benzodiazepine receptors. GABA blocks other activity in your brain, which helps you feel calm and can make you sleepy.

The structure of benzodiazepines is made up of a benzene ring fused to a seven-membered 1,4 diazepine ring. Alprazolam is administered orally and is directly metabolized by hepatic microsomal oxidation (Jahn et al., 2016). They have a peak plasma concentration which occurs after 1 to 2 hours of being taken. Another drug is chlordiazepoxide which although itself has an intermediate half-life (6 — 28 h), its active metabolite desmethyldiazepam has a very long half-life; oral chlordiazepoxide is rapidly and completely absorbed and its volume of distribution varies from 0.25 to 0.50 l/kg. The drug seems to block electroencephalogram arousal from stimulation in the brain stem reticular formation.

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Another type of anxiolytic drug that has been approved to treat GAD is the Selective serotonin reuptake

NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder
NURS 6521 Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

inhibitor (SSRI) drug that works by inhibiting serotonin reuptake transporter and this inhibition of the 5-HT increases the concentration of synaptic hence increasing the extra-synaptic diffusion. An example of SSRIs is fluoxetine which is metabolized through the CYP2D6 system, inhibits CYP2D6 activity, and exhibits considerable intra-individual variability in tolerability and response (Strawn et al., 2018). It also has noradrenergic and dopaminergic effects which putatively underlie its therapeutic efficacy. SNRI is another type of anxiolytic drug used for treating GAD. An example of SNRI such as venlafaxine has been approved by Food Drug Administration to treat GAD. The pharmacokinetics and pharmacodynamics of venlafaxine work through active metabolite, odesmethylvenlafaxine by inhibiting the serotonin and norepinephrine reuptake transporters albeit with greater potency at the norepinephrine transporter (Gravelle, 2016). Duloxetine has been approved by the FDA to treat GAD. Its pharmacodynamics and pharmacokinetics include the reuptake inhibition of serotonin and norepinephrine at the presynaptic neuron in Onuf’s nucleus of the sacral spinal cord ( ).

Another group of anxiolytic medications used is Non-benzodiazepine Sedative-Hypnotics such as eszopiclone which works by interaction with GABA receptor complexes at binding domains located close to or allosterically coupled to benzodiazepine receptors. Other types of anxiolytic medications are Second-generation antipsychotics (SGAs), Antihistamines, GABA-related interventions, and Tricyclic Antidepressants.

In conclusion, the choice of anxiolytic drug to be prescribed is dependent on the pharmacokinetics and pharmacodynamics factors that might affect the efficacy of the drug. It has been observed that SSRIs and SNRIs are considered the most effective while benzodiazepine and other types of drugs come second. An expert opinion argues that there is a need for healthcare providers to take an optimal pharmacological approach towards integrative pharmacokinetic and pharmacodynamics optimization strategy that would ensure better treatment and personalization of anxiety disorders. According to Almatura et al. (2013), this approach would help in the development of new anxiolytic drugs that are more effective and have limited side, especially benzodiazepines drugs.

 References

Altamura, A. C., Moliterno, D., Paletta, S., Maffini, M., Mauri, M. C., & Bareggi, S. (2013). Understanding the pharmacokinetics of anxiolytic drugs. Expert opinion on drug metabolism & toxicology9(4), 423-440.

Gravielle, M. C. (2016). Activation-induced regulation of GABAA receptors: is there a link with the molecular basis of benzodiazepine tolerance?. Pharmacological Research109, 92-100.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy19(10), 1057-1070.

Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., … & Stanley, M. A. (2010). Generalized worry disorder: a review of DSM‐IV generalized anxiety disorder and options for DSM‐V. Depression and anxiety, 27(2), 134-147.

Jann, Michael W.; Penzak, Scott R.; Cohen, Lawrence J. (2016). Applied Clinical Pharmacokinetics and Pharmacodynamics of Psychopharmacological Agents || Clinical Pharmacokinetics and Pharmacodynamics of Anxiolytics and Sedative/Hypnotics. , 10.1007/978-3-319-27883-4(Chapter 10), 247–266. doi:10.1007/978-3-319-27883-4_10

Sertraline is a type of SSNIs that is slowly absorbed from the gastrointestinal tract with peak serum levels occurring between 6 and 8 hours after administration. Its absorption is significantly influenced by co-administration with food, which may hasten absorption by 1–2 hours (Huddart et al., 2020). Sertraline is primarily metabolized by CYP2C19 and CYP2B6 and has a half-life of 26–32 hours in adults, although this half-life varies as a function of the CYP2C19 phenotype. In children, the half-life of sertraline is significantly lower. Although it is commonly used in the treatment of GAD, there are some PK and PD which might interfere with its process. For example, age may influence sertraline pharmacokinetics among elderly patients since they have increased serum concentrations and concentration/dose (C/D) ratios of sertraline and desmethylsertraline, compared to younger patients. Another PK and PD factor affecting the sertraline process is having liver disease can affect the elimination of sertraline. Patients with cirrhosis have a significantly increased exposure to sertraline compared to patients with no hepatic impairment. For example, for pregnant women, the metabolism of sertraline may be increased, which results in the potential need for dose increases during pregnancy.

Due to their high lipophilicity, sertraline and desmethyl sertraline can be detected in breast milk and in the plasma of breastfed infants of sertraline-treated mothers (Freeman et al., 2008).

References

Huddart, R., Hicks, J. K., Ramsey, L. B., Strawn, J. R., Smith, D. M., Babilonia, M. B., … & Klein, T. E. (2020). PharmGKB summary: sertraline pathway, pharmacokinetics. Pharmacogenetics and genomics30(2), 26.

Freeman, M. P., Nolan Jr, P. E., Davis, M. F., Anthony, M., Fried, K., Fankhauser, M., … & Moreno, F. (2008). Pharmacokinetics of sertraline across pregnancy and postpartum. Journal of clinical psychopharmacology28(6), 646-653.

  Summary of Patient Case Study

A 71-year-old Asian man with a history of GAD, which was caused by diabetes and hypertension, was presented to our inpatient psychiatric clinic. He was mainly brought for stabilization and long-term medication. The information gathered from the family stated that the patient had refused oral food intake for about thirty hours, was isolative in his room, and had increased confusion. The diagnosis also showed a history of GAD in the patient’s family, especially among aged people. After admitting him to our clinic, the clinical presentation of the patient depicted a transformed level of consciousness. I took three imperative decisions I thought could help him. They include: stabilizing him, performing psychotherapy, and administering relevant medication.

Evaluation of My Decisions

I believe the decisions I provided were supported by evidence-based literature. According to Watts et al. (2020), psychotherapy involves working with therapists to reduce the level of GAD. For example, in our case, I recommended the therapist to use behavioral therapy because it was the most effective psychotherapy for GAD. On the other hand, stabilizing the patient is imperative because it ensures the conditions of the patient are within the healthy range (Savioli et al., 2020). For example, in our case, I recommended calming the patient to regain his level of consciousness.  Lastly, I recommended the patient’s medication because it could ease symptoms and prevent or halt hypertension and diabetic conditions (Wilhelmsen & Eriksson, 2019). Medication was the heart of everything because the patient’s issues were beyond anxiety disorders.

Objectives of My Decisions

First, I hoped behavioral therapy could help the patient manage various GAD-related symptoms, such as anxiety and stress. I also expected this treatment option could help the patient cope with negative emotions. Second, I hoped the medication decisions I recommended, such as Crestor 20mg daily, Lantus insulin 10 units daily, Metformin 70mg daily, Lithium 300mg daily, and hydrochlorothiazide 25mg daily, could help the patient improve his hypertension and diabetic conditions. Lastly, I hoped the patient would be stable after recommending a stabilization program in the emergency room. I also expected his pressure to normalize after calming him by providing personal attention.

Differences between Expectations and Results

In psychotherapy, the expected results were attained. For example, the patient coped with adverse emotions and managed his anxiety and stress. He calmed down and started conversing with me. On the other hand, the prescribed medication also responded positively as planned. For example, in this decision, I aimed to improve the patient’s diabetic condition, which came down to manageable levels. Therefore, there was no difference between the anticipated and results. Lastly, the objectives of my decision to stabilize the patient aligned with the outcomes. For example, the patient’s hypertension was very high, but I managed to bring it to normal levels.

Pharmacokinetics and Pharmacodynamics Processes

In the pharmacokinetics process, the medication I recommended, especially oral medication, undergoes three stages. Absorption is the first stage, where the medicine is ingested and passed through the stomach into the intestine linings. The second stage is distribution, where the drugs pass through the liver and intestines into the bloodstream. The third stage is metabolism, where the drug undergoes glucuronidation and oxidation. The last stage is the excretion of the medicine, mainly through the functioning of the kidney. The pharmacodynamics commences when the drug reaches the target organ or tissue. The drug may involve enzyme inhibition or cause presynaptic or postsynaptic effects on the patient. The final part of pharmacodynamics involves cellular response and signal transduction.

 

References

Savioli, G., Ceresa, I. F., Manzoni, F., Ricevuti, G., Bressan, M. A., & Oddone, E. (2020). Role of a brief intensive observation area with a dedicated team of doctors in the management of acute heart failure patients: a retrospective observational study. Medicina56(5), 251.

Watts, S., Marchand, A., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., & Dugas, M. J. (2020). Telepsychotherapy for generalized anxiety disorder: Impact on the working alliance. Journal of Psychotherapy Integration30(2), 208.

Wilhelmsen, N. C., & Eriksson, T. (2019). Medication adherence interventions and outcomes: an overview of systematic reviews. European Journal of Hospital Pharmacy26(4), 187-192.