Anxiolytic
Anxiolytic | |
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Anxiety disorders | |
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An anxiolytic (
Nature of anxiety
Anxiety is a naturally-occurring emotion and response. When anxiety levels exceed the tolerability of a person,
Type | Description |
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Generalized anxiety disorders (GAD) | The anxiety symptoms are usually persistent and constant. Patients of this disorder could experience excessive anxiety for a long duration, commonly over six months and the symptoms could occur without any specific triggers. |
Panic disorder | This disorder specifically refers to the suffering from panic attacks and also the fear of repetitive attacks. Commonly found in agoraphobia patients (the fear of difficulty in leaving a confined venue). Panic attacks are sudden upsurges in anxiety level usually with unexplained reasons. |
Social phobia
|
This refers to the fear of staging in social situations where one experiences public observation among people or performs in front of the public. The fears are often unexplained and persistent. The fear could also be attributed to the possible humiliation in front of others due to poor performance or awkward social interactions. |
Specific phobias | Persistent fear towards a specific object, either tangible or intangible. This leads to undeniable avoidance or thought of escape from the object or endurance of the object in immense levels of anxiety. |
Posttraumatic stress disorder (PTSD) | PTSDs develop due to experience of severe trauma or life-threatening events. Specific symptoms include flashbacks to traumatic events triggered during similar situations, as well as avoidance of these situations. The fear of re-experiencing the event is also associated with feelings of helplessness or horror. |
Obsessive–compulsive disorder (OCD) | Person with OCD would experience compulsive impulses of removing an obsession. One common example is the obsession with impurities or contamination. The person would have compulsion or urge in sterilizing the environment to remove the contamination. Another example is the obsession with orderliness. The person would manipulate the surroundings including visual presentations to ease their obsession. |
Different types of anxiety disorders will share some general symptoms while having their own distinctive symptoms. This explains why people with different types of anxiety disorders will respond differently to different classes of anti-anxiety medications.
Etiology
The etiology of anxiety disorder remains unknown. There are several contributing factors that are still yet to be proved to cause anxiety disorders.[2] These factors include childhood anxiety, drug induction by central stimulant drugs, metabolic diseases or having depressive disorder.
Medications
Anti-anxiety medication is any drug that can be taken or prescribed for the treatment of
Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCA), monoamine oxidase inhibitor (MAOI). SSRIs are used in all types of anxiety disorders while SNRIs are used for generalized anxiety disorder (GAD). Both of them are considered as first-line anti-anxiety medications. TCAs are second-line treatment as they cause more significant adverse effects when compared to the first-line treatment. Benzodiazepines are effective in emergent and short-term treatment of anxiety disorders due to their fast onset but carry the risk of dependence.[4] Buspirone is indicated for GAD, which has much slower onset but with the advantage of less sedating and withdrawal effects.[5]
History
The first monoamine oxidase inhibitor (MAOI), iproniazid, was discovered accidentally when developing the new antitubercular drug isoniazid. The drug was found to induce euphoria and improve the patient's appetite and sleep quality.[6]
The first tricyclic antidepressant, imipramine, was originally developed and studied to be an antihistamine alongside other first-generation antihistamines of the time, such as promethazine.[7] TCAs can increase the level of norepinephrine and serotonin by inhibiting their reuptake transport proteins.[8] The majority of TCAs exert greater effect on norepinephrine, which leads to side effects like drowsiness and memory loss. [citation needed]
In order to be more effective on serotonin agonism and avoid anticholinergic and antihistaminergic side effects, selective serotonin reuptake inhibitors (SSRI) were researched and introduced to treat anxiety disorders. The first SSRI, fluoxetine (Prozac), was discovered in 1974 and approved by FDA in 1987. After that, other SSRIs like sertraline (Zoloft), paroxetine (Paxil), and escitalopram (Lexapro) have entered the market.[7]
The first serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine (Effexor), entered the market in 1993.[7] SNRIs can target serotonin and norepinephrine transporters while avoiding imposing significant effects on other adrenergic (α1, α2, and β), histamine (H1), muscarinic, dopamine, or postsynaptic serotonin receptors.[citation needed]
Classifications
There are six groups of anti-anxiety medications available that have been proven to be clinically significant in treatment of anxiety disorders.[9] The groups of medications are as follows.
Drug Class | Examples |
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Antidepressants (e.g., SSRIs, SNRIs) | SSRIs e.g., fluoxetine, sertraline; SNRIs e.g., venlafaxine; MAOIs; TCAs |
Benzodiazepines | Lorazepam, diazepam, alprazolam |
Azapirones | Buspirone, gepirone, tandospirone |
Antiepileptics | Gabapentin, pregabalin, tiagabine and valproate |
Antipsychotics | Olanzepine, risperidone |
Beta-adrenoceptor antagonists | Propranolol, atenolol |
Antidepressants
Medications that are indicated for both anxiety disorders and depression. Selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are new generations of antidepressants. They have a much lower adverse effect profile than older antidepressants like monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressant (TCAs). Therefore, SSRIs and SNRIs are now the first-line agent in treating long term anxiety disorders, given their applications and significance in all six types of disorders.[9]
Benzodiazepines
Benzodiazepines are used for acute anxiety and could be added along with current use of SSRIs to stabilize a treatment. Long-term use in treatment plans is not recommended. Different kinds of benzodiazepine will vary in its pharmacological profile, including its strength of effect and time taken for metabolism. The choice of the benzodiazepine will depend on the corresponding profiles.[9]
Benzodiazepines are used for emergent or short-term management. They are not recommended as the first-line anti-anxiety drugs, but they can be used in combination with SSRIs/SNRIs during the initial treatment stage.[4] Indications include panic disorder, sleep disorders, seizures, acute behavioral disturbance, muscle spasm and premedication and sedation for procedures.[10]
Azapirones
Buspirone can be useful in GAD but not particularly effective in treating phobias, panic disorder or social anxiety disorders.[2] It is a safer option for long-term use as it does not cause dependence like benzodiazepines. [11]
Antiepileptics
Antiepileptics are rarely prescribed as an off-label treatment for anxiety disorders and post-traumatic stress disorders.[12] There have been some suggestions that they may help with anxiety symptoms but there is generally a lack of research on its use.[13]
One antiepileptic, pregabalin, has been found to be better at treating GAD than a placebo, and comparable effects to benzodiazepines. It has also been shown be potentially efficient in treating social anxiety disorder. Gabapentin has been prescribed off-label for anxiety despite a lack of research evidence supporting such use, although some studies have indicated that it may relieve anxiety symptoms. The potential anxiolytic effect of tiagabine has been observed in some pre-clinical trials, but its effectiveness has not yet been proved. Similarly, there is a lack of research on valproate for the treatment of anxiety disorders.[13]
Antipsychotics
Olanzapine and risperidone are atypical antipsychotics which are also effective in GAD and PTSD treatment. However, there is a higher chance of experiencing adverse effects than the other anti-anxiety medications.[9]
Beta-adrenoceptor antagonists
Propranolol is originally used for high blood pressure and heart diseases. It can also be used to treat anxiety with symptoms like tremor or increased heart rate. They work on the nervous system and alleviate the symptoms as a relief.[9] Propranolol is also commonly used for public speaking when one is nervous.[13]
Mechanism of action
SSRIs and SNRIs
Both selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) are reuptake inhibitors of a class of nerve signal transduction chemical called
Benzodiazepine
Benzodiazepines bind selectively to the
Clinical use
Selective serotonin reuptake inhibitors
SSRIs can increase anxiety initially due to negative feedback through the serotonergic
The SSRIs paroxetine and escitalopram are USFDA approved to treat generalized anxiety disorder.[13]
Therapeutic use
Drug | Indication | Common side effect |
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Citalopram | ||
Escitalopram[18]
(active enantiomer of citalopram) |
|
|
Fluoxetine[18] |
|
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Adverse effect
The common early side effects of SSRIs include nausea and loose stool, which can be solved by discontinuing the treatment. Headache, dizziness, insomnia are the common early side effects as well.[20]
Withdrawal symptoms like dizziness, headache and flu-like symptoms (fatigue/myalgia/loose stool) may occur if SSRI is stopped suddenly. The brain is incapable of upregulating the receptors to sufficient levels especially after discontinuation of the drugs with short half life like paroxetine. Both fluoxetine and its active metabolite have a long half life therefore it causes the least withdrawal symptoms.[16][22]
Serotonin–norepinephrine reuptake inhibitors
Tricyclic antidepressants
Therapeutic use
Drugs | Indication | Common side effect |
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Imipramine |
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Clomipramine[18] |
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Contraindication
TCAs may cause drug poisoning in patients with hypotension, cardiovascular diseases and arrhythmias.[26]
Tetracyclic antidepressants
Mirtazapine has demonstrated anxiolytic effect comparable to SSRIs while rarely causing or exacerbating anxiety. Mirtazapine's anxiety reduction tends to occur significantly faster than SSRIs.[27]
Monoamine oxidase inhibitors
Barbiturates
Barbiturates are powerful anxiolytics but the risk of abuse and addiction is high. Many experts consider these drugs obsolete for treating anxiety but valuable for the short-term treatment of severe insomnia, though only after benzodiazepines or non-benzodiazepines have failed.[29]
Benzodiazepines
Benzodiazepines include: alprazolam (Xanax), bromazepam, chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), oxazepam, temazepam, and Triazolam.
Therapeutic use
Drug | Indication | Common Side effect |
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Lorazepam |
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Diazepam |
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Alprazolam |
|
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Adverse effect
Benzodiazepines lead to central nervous system depression, resulting in common adverse effects like drowsiness, oversedation, light-headedness. Memory impairment can be a common adverse effect especially in elderly, hypersalivation, ataxia, slurred speech, psychomotor effects.[2]
Sympatholytics
Miscellaneous
Buspirone
Buspirone (Buspar) is a 5-HT1A receptor agonist used to treated generalized anxiety disorder.[37] If an individual has only recently stopped taking benzodiazepines, buspirone will be less effective.[38]
Pregabalin
Hydroxyzine
Hydroxyzine (Atarax) is an antihistamine originally approved for clinical use by the FDA in 1956. Hydroxyzine has a calming effect which helps ameliorate anxiety. Hydroxyzine efficacy is comparable to benzodiazepines in the treatment of generalized anxiety disorder.[41]
Phenibut
Temgicoluril
Fabomotizole
Fabomotizole (Afobazole) is an anxiolytic drug launched in Russia in the early 2000s. Its mechanism of action is poorly-defined, with GABAergic, NGF and BDNF release promoting, MT1 receptor agonism, MT3 receptor antagonism, and sigma receptor agonism thought to have some involvement.[49][50]
Bromantane
Bromantane is a stimulant drug with anxiolytic properties developed in Russia during the late 1980s. Bromantane acts mainly by facilitating the biosynthesis of dopamine, through indirect genomic upregulation of relevant enzymes (tyrosine hydroxylase (TH) and aromatic L-amino acid decarboxylase (AAAD)).[51][52]
Emoxypine
Emoxypine is an antioxidant that is also a purported anxiolytic.[53][54] Its chemical structure resembles that of pyridoxine, a form of vitamin B6.
Menthyl isovalerate
Menthyl isovalerate is a flavoring food additive marketed as a sedative and anxiolytic drug in Russia under the name Validol.[55][56]
Racetams
Some racetam based drugs such as aniracetam can have an antianxiety effect.[57]
Alpidem
Etifoxine
Alcohol
Alternatives to medication
Cognitive behavioral therapy (CBT) is an effective treatment for panic disorder, social anxiety disorder, generalized anxiety disorder, and obsessive–compulsive disorder, while exposure therapy is the recommended treatment for anxiety related phobias. Healthcare providers can guide those with anxiety disorder by referring them to self-help resources.[61] Sometimes medication is combined with psychotherapy but research has not found a benefit of combined pharmacotherapy and psychotherapy versus monotherapy.[62]
If CBT is found ineffective, both the Canadian and American medical associations then suggest the use of medication.[63][verification needed]
See also
Categories
References
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External links
- Media related to Anxiolytics at Wikimedia Commons