What is the best course of action for a 58-year-old female with anxiety, insomnia, intermittent edema, and paresthesia, and incomplete cardiology and pulmonology workups?

From the Guidelines

For this 58-year-old female with anxiety, insomnia, and symptoms of peripheral edema and neuropathic pain, I recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment, as suggested by the American College of Physicians guideline 1. This approach is supported by moderate-quality evidence and is considered a strong recommendation. The patient's symptoms of anxiety and insomnia can be addressed through CBT-I, which is a multimodal cognitive behavioral therapy targeted specifically to insomnia, consisting of a combination of cognitive therapy, behavioral interventions, and educational interventions. Additionally, the patient's neuropathic symptoms (burning sensations in hands and feet) can be managed with medications such as gabapentin, but this should be considered after CBT-I has been initiated, as per the guideline's recommendation to use a shared decision-making approach for pharmacological therapy 1. It's also essential to obtain her recent laboratory results, particularly kidney function tests, before finalizing any medication regimen, as gabapentin dosing may need adjustment with impaired renal function. The patient should also be reconnected with cardiology for follow-up on her previous workup and to evaluate the edema from a cardiovascular perspective. While she declined neurology referral now, this should be revisited if symptoms persist despite medication therapy. A follow-up appointment should be scheduled in 2-4 weeks to assess treatment efficacy and tolerability. Some key points to consider in her treatment plan include:

• The importance of CBT-I as the initial treatment for chronic insomnia disorder, as recommended by the American College of Physicians guideline 1
• The potential benefits of gabapentin in managing neuropathic pain and promoting sleep, as well as its potential side effects and interactions 1
• The need for regular follow-up appointments to monitor treatment efficacy and tolerability, and to adjust the treatment plan as needed.

From the FDA Drug Label

Anxiety Disorders and Transient Symptoms of Anxiety Treatment for patients with anxiety should be initiated with a dose of 0.25 to 0.5 mg given three times daily. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses.

The patient's symptoms of anxiety can be managed with alprazolam. The recommended initial dose is 0.25 to 0.5 mg given three times daily, with a maximum daily dose of 4 mg.

• The dose should be increased cautiously to avoid adverse effects.
• The need for continued treatment should be reassessed frequently.
• The risk of dependence may increase with dose and duration of treatment 2.
• The patient's dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage 2.

From the Research

Patient Presentation

The patient is a 58-year-old female with a past medical history (PMH) of anxiety and insomnia, presenting to re-establish care and refill medications. She reports experiencing occasional edema in her feet when standing for prolonged periods and sometimes in her hands, along with occasional burning sensations in both her hands and feet.

Medication Considerations

• The patient's symptoms of edema and burning sensations may be related to her medication regimen, as evidenced by studies on gabapentin-induced edema 3, 4.
• Gabapentin is commonly used to treat anxiety, insomnia, and other conditions, but it can cause side effects such as edema, hyperesthesia, and scaling 3.
• The patient's history of anxiety and insomnia may be relevant to her medication regimen, as gabapentin has been used to treat generalized anxiety disorder (GAD) 5.

Diagnostic Considerations

• The patient's symptoms of edema and burning sensations may be related to underlying cardiovascular or neurological conditions, which should be further evaluated through laboratory tests and imaging studies.
• The patient's previous cardiology workup, including Doppler and echocardiogram, should be reviewed to determine if any underlying conditions were identified 4.
• The patient's referral to a pulmonologist and sleep study may also be relevant to her diagnosis and treatment plan.

Treatment Options

• The patient's medication regimen should be carefully evaluated to determine if any changes can be made to alleviate her symptoms of edema and burning sensations.
• Alternative medications or dosage adjustments may be considered to minimize side effects and optimize treatment outcomes 5, 6.
• The patient's treatment plan should be individualized to address her specific needs and medical history.

Patient History and Communication

• Taking a comprehensive patient history is essential for accurate diagnosis and effective management of health conditions 7.
• The patient's history of anxiety, insomnia, and other medical conditions should be carefully reviewed to identify potential contributing factors to her symptoms.
• Effective communication and active listening are critical for building trust and ensuring patient participation in the treatment plan 7.