Anxiety Medications (cont.)
Omudhome Ogbru, PharmD
Dr. Ogbru received his Doctorate in Pharmacy from the University of the Pacific School of Pharmacy in 1995. He completed a Pharmacy Practice Residency at the University of Arizona/University Medical Center in 1996. He was a Professor of Pharmacy Practice and a Regional Clerkship Coordinator for the University of the Pacific School of Pharmacy from 1996-99.
In this Article
- What are anxiety medications and how do they work?
- For what conditions are anxiety medications used?
- Which anxiety medication is used depends on the specific diagnosis
- Are there differences among anxiety medications?
- What are the warnings/precautions/side effects and adverse events of anti-anxiety medications?
- What are some drug interactions for anti-anxiety drugs?
- What are some examples of anxiety medications?
What are the warnings/precautions/side effects of anti-anxiety medications?
- All antidepressants may increase the risk of suicide in children, adolescents, and young adults up to the age of 24. Also, using other antidepressants with MAO inhibitors poses the serious risk of developing severe, possibly fatal side effects. A space of 14 days needs to be allowed between the use of the two types of drugs.
- Abrupt withdrawal of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) may result in anxiety, confusion, dizziness, and agitation.
- Other drugs that interfere with coagulation, including aspirin and other nonsteroidal anti-inflammatory medications, should be avoided when using SSRIs and SNRIs.
- Combining SSRIs or SNRIs with tryptophan, migraine drugs known as triptans, and other drugs that increase serotonin levels may lead to a serious, life-threatening reaction.
- Some SSRIs and SNRIs may cause a drop in blood sodium levels, especially in dehydrated patients, the elderly, or those using diuretics.
- If a patient develops a rash while using fluoxetine (Prozac), the medication should be discontinued, as this might indicate a serious allergic or other reaction. Fluoxetine commonly causes insomnia and may cause significant weight loss.
- Duloxetine (Cymbalta) can cause liver damage and should not be used by alcohol abusers or by those with pre-existing liver disease. It may also cause dizziness on standing or even fainting early in therapy.
- Venlafaxine (Effexor) may significantly increase cholesterol levels. It may also decrease appetite and cause weight loss. Some patients may experience a sustained increase in blood pressure when using venlafaxine. And venlafaxine should be used with caution in patients with glaucoma.
- Mirtazapine (Remeron) may rarely cause a serious blood disorder called agranulocytosis. If fever, sore throat, or other signs of infection develop while on mirtazapine, and white blood cell counts are elevated, the medication should be discontinued. Mirtazapine may cause an increase in appetite and weight gain. It may also cause drowsiness and/or dizziness. And it can increase cholesterol and triglyceride levels as well as affect liver enzyme levels.
- Some tricyclic antidepressants (TCAs) may cause drowsiness. Anticholinergic side effects commonly occur with TCAs. These include dry mouth, urinary retention, blurry vision, and constipation. TCAs also interact with a wide array of drugs, sometimes with fatal results. Additionally, TCAs are a significant cause of death from drug overdoses.
- Patients with cardiac disease may need to avoid use of tricyclic antidepressants, and TCAs should not be used in the recovery period immediately following a heart attack.
- TCAs should be used with caution in patients with glaucoma and history of seizures.
- With monoamine oxidase inhibitors, it's important to monitor blood pressure during therapy. If palpitations or headache occur while MAOIs are being used, treatment should be stopped, as these may be signs of a potentially fatal hypertensive crisis.
- Foods containing tyramine should not be eaten while using MAOIs. Doing so may trigger a hypertensive crisis. These would include foods smoked, aged, pickled, or fermented -- or food with natural bacterial contamination. Examples of such foods include beer, wine, yeast, liver, dry sausages, fava beans, and yogurt.
- MAOIs interact with a wide array of prescription and nonprescription drugs. Patients should make sure doctors and other health care professionals know they are using these medications.
- Patients using MAOIs may experience drowsiness and dizziness; insomnia is also possible. Other side effects of MAOIs include weight gain, sexual dysfunction, constipation, and other gastrointestinal problems.
- Trazodone (Desyrel) can cause priapism (sustained, painful erections). It can also cause drowsiness. Food significantly affects absorption of trazodone in some patients. Therefore, trazodone should be taken after a meal or snack.
- Bupropion (Wellbutrin) may increase the risk of seizures, especially at higher doses. It may also cause a significant increase in blood pressure. About one out of every three patients using bupropion experiences insomnia. Bupropion may cause dry mouth.
- Sweating, constipation, and loss of appetite have been reported with desvenlafaxine. Eye pain, visual changes, and ocular swelling are possible with desvenlafaxine.
- Erectile dysfunction, increased heart rate and/or palpitations, sweating, and constipation are common side effects of levomilnacipran.
- The most common side effect with milnacipran is nausea. Taking it with food can minimize the discomfort.
- Atomoxetine may increase suicidal thoughts in teens and children. Other atomoxetine side effects include dizziness, tiredness, mood swings, nausea, vomiting, decreased appetite, trouble urinating, and sexual side effects.
- Nefazodone may increase suicidal thoughts in children and young adults.
Anxiolytics (Anti-Anxiety Medications)
- Benzodiazepines should not be abruptly stopped because of the risk of seizures and other serious side effects. It is dangerous to combine benzodiazepines with other central nervous system depressants, including alcohol. Doing so may cause profound drowsiness and/or impair breathing. Those who have breathing difficulties such as sleep apnea or chronic obstructive pulmonary disease (COPD) should not use benzodiazepines.
- Benzodiazepines frequently cause drowsiness; therefore, care should be taken when operating machinery or motor vehicles.
- Side effects of antihistamines include drowsiness and dry mouth.
- The anticonvulsant divalproex (Depakote) may cause life-threatening liver and pancreatic toxicities; it is also associated with causing birth defects. Divalproex may interfere with blood coagulation. Lethargy is a common side effect of divalproex, but if it's accompanied by vomiting and confusion it may indicate a more serious problem called hyperammonemia in which blood ammonia levels become elevated.
- Tiagabine (Gabitril) at certain dosage levels, or with increases in dose, may induce seizures even in those who have never had them. It may also cause problems with concentration, drowsiness, and dizziness.
- Anticonvulsant medications should not be withdrawn suddenly because of the risk of seizures.
- In pediatric patients, the anticonvulsant gabapentin (Neurontin) may cause behavioral problems, including restlessness, agitation, and hostility. Gabapentin may cause drowsiness.
- Lamotrigine (Lamictal) has caused life-threatening and disfiguring rashes. At the first sign of rash, the medication should be discontinued. There is no guarantee though, the rash won't continue to progress once the drug is withdrawn. Coagulation problems and other blood-related issues may also occur with this drug. It may increase suicidal thoughts or behaviors. It may cause dizziness and drowsiness.
- Use of the anticonvulsant topiramate (Topamax) may cause metabolic acidosis. Symptoms include fatigue and anorexia. Patients using topiramate should have blood bicarbonate levels monitored.
- Topiramate can cause visual changes, including decreased acuity along with eye pain. This may necessitate withdrawal of the drug to prevent permanent visual loss. Decreased sweating and the resultant increase in body temperature, sometimes severe enough to require hospitalization, may occur with topiramate. Patients should be monitored for sweat output, especially in hot weather. Side effects of topiramate include difficulty concentrating, behavioral changes, and drowsiness.
- Levetiracetam may cause mood swings, hallucinations, and unusual behaviors -- as well as fatigue, weakness, and problems walking or moving.
- Pregabalin commonly cause dizziness as well as sleepiness. It may also cause life-threatening allergic reactions.
- Vigabatrin is under a restricted-use program primarily because it can cause vision loss in anyone who takes it, at any dose. Visual loss commonly includes loss of peripheral vision. Vigabatrin has also been linked to suicidal thoughts.
- Beta-blockers should not be withdrawn suddenly because severe cardiac problems, including heart attacks, may occur. Beta-blockers also should not be used in patients with certain breathing disorders, including bronchitis and emphysema.
- Beta-blockers can mask signs and symptoms of hypoglycemia and overactive thyroid disease. Dizziness and drowsiness can occur with beta-blockers.
- The alpha-blocker prazosin (Minipress) can cause dizziness and lightheadedness, both common side effects. Early in treatment, fainting can occur, especially when standing up.
- The alpha-blockers clonidine (Catapres) and guanfacine (Tenex) may cause dry mouth, drowsiness, dizziness, constipation, sedation, and weakness.
- An increased risk of death is seen in elderly patients with dementia-related psychosis who use antipsychotic drugs. These drugs may also increase the risk of suicidal thinking and behavior in younger patients.
- Movement disorders may develop during the use of antipsychotics. Especially with prolonged use, tardive dyskinesia may become irreversible. Antipsychotics may cause hypoglycemia, which can be life-threatening.
- Neuroleptic malignant syndrome, characterized by high fever, muscular rigidity, and abnormal cardiac symptoms, may occur with antipsychotics.
- Drowsiness is a common side effect of antipsychotics. They may also cause difficulty swallowing. Antipsychotics may interfere with the body's ability to control core temperature, therefore, exercise caution in situations that raise body temperature (strenuous exercise, hot weather).
- The antipsychotic ziprasidone (Geodon) prolongs the QT interval, which could lead to fatal heart arrhythmias in some patients. Ziprasidone should not be given to those with a history of QT prolongation or to those who may be taking other drugs that prolong the QT interval.
- The antipsychotic risperidone (Risperdal) may increase the risk of cerebrovascular events, such as stroke, in elderly patients with dementia-related psychosis.
- Patients taking the antipsychotic quetiapine (Seroquel) should be examined for cataracts and other changes to the eyes. This drug may also cause dizziness, fainting, and drowsiness.
- The antipsychotic olanzapine (Zyprexa) may elevate triglyceride levels and cause weight gain. Common side effects include drowsiness, dry mouth, and dizziness.
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