Effexor XR 37.5mg PO daily (this dose will be increased as tolerated at weekly intervals until therapeutic dose is achieved)
6. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.
I chose to prescribe this patient Effexor for several reasons. The first-line treatments for generalized anxiety disorder include SSRIs, SNRIs, buspirone, benzodiazepines, and alpha 2 delta ligands (Stahl, 2013). Additionally, the first-line treatments for panic disorder include SSRIs, SNRIs, alpha 2 delta ligands, and benzodiazepines (Stahl, 2013). Antidepressants are arguably the most effective medications for anxiety (Puzantian and Carlat, 2018). Effexor is approved by the FDA for the treatment of MDD, GAD, social anxiety disorder, and panic disorder (Puzantian & Carlat, 2018). Diaper et al. (2013) report that Effexor has proven to be a significantly effective treatment in generalized anxiety disorder, panic disorder, and social anxiety disorder. Ural, Belli, Tabo, and Akbudak (2015) report that Effexor is an optimal medication choice in the treatment of panic and anxiety due to the exceptional treatment efficacy and advantages in side effect profiles.
Effexor is a potent inhibitor of neuronal serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake (Lexicomp, 2018). Effexor boosts serotonin, norepinephrine/noradrenaline, and dopamine levels (Stahl, 2013). Effexor has no significant activity on muscarinic cholinergic, H1 histaminergic, or alpha 2 adrenergic receptors (Stahl, 2013).
7. What laboratory testing/monitoring is needed for safely prescribing this medication?
Blood pressure should be checked before initiating treatment and periodically during treatment with Effexor (Stahl, 2013). No routine laboratory testing is required with the use of Effexor.
8. Are there any contraindications or safety issues associated with this medication?
A black box warning regarding an increased risk of suicidal ideation in children, adolescents, and young adults up to age 24 was added to the labeling on all medication approved for the treatment of depression (Puzantian & Carlat, 2018). All serotonergic agents pose a risk for inducing serotonin syndrome; however, this condition is primarily associated with the use of multiple or high dose serotonergic agents (Puzantian & Carlat, 2018). Serotonin syndrome is a potentially life-threatening condition characterized by labile blood pressure, hallucinations, myoclonus, agitation, nausea, vomiting, diarrhea, and hyperthermia (Puzantian & Carlat, 2018). Abrupt discontinuation of Effexor can result in discontinuation syndrome. Discontinuation syndrome is characterized by irritability, headache, nausea, dizziness, insomnia, and agitation (Puzantian & Carlat, 2018). Seizures and hypomania are rare but potentially serious side effects of Effexor (Stahl, 2013). Zullino and Cucchia (2014) report that hypertension is a well-known and potentially dangerous side effect of Effexor. Effexor can cause a dose-dependent increase in blood pressure; therefore, blood pressure should be monitored throughout treatment (Stahl, 2013). Effexor may cause hyponatremia or SAIDH; therefore, this medication should be used with caution in patients who are dehydrated, elderly, or prescribed diuretics (Puzantian & Carlat, 2018). Contraindications of Effexor include allergy to Effexor or any component of the medication, concurrent use of MAOIs, and concurrent use of linezolid (Lexicomp, 2018).
13. What non-pharmacologic interventions do you recommend?
I believe cognitive behavioral therapy (CBT) would be significantly beneficial for this patient. Moberg, Niles, and Beermann (2019) report that CBT is among the best-researched and clinically proven effective nonpharmacological treatments for depression and anxiety. CBT is a common form of psychotherapy in which patients become aware of inaccurate or negative thinking in order to view challenging situations more clearly and respond to them in a more effective way (Mayo Clinic, 2019). CBT is an effective tool to help individuals learn how to better manage stressful life situations (Mayo Clinic, 2019). Cuijpers et al. (2012) report that several studies have proven that psychiatric medication, as well as psychotherapies, have significant impacts on mental health disorders, that both are about equally effective, and that combined treatments are significantly more effective than either psychotherapy or medication management alone.
Another non-pharmacologic intervention that would be beneficial for this patient is mindfulness-based meditation. Saeed, Cunningham, and Bloch (2019) report that mindfulness-based meditation is a form of mental training that requires calming the mind with the goal of achieving a state of detached observation. Saeed et al. (2019) report that mindfulness based meditation has been studied in several randomized controlled trials and has been proven significantly effective in reducing anxiety symptoms and improving mood.
- Do you agree/disagree with their medication choice? Why?
- Is there anything else you recommend including?
- Compare peer’s decision making to yours—what are the advantages and disadvantages of each?