From the Guidelines
For a patient with worsening anxiety and normal lab results, including a 24h cortisol level of 200, I recommend starting with non-pharmacological approaches, given the potential impact of elevated cortisol on anxiety symptoms, and considering the patient's recent anxiety worsening, a comprehensive approach is necessary. The patient's lab results, including CBC, CMP, TSH, and fasting glucose, are all within normal limits, which helps to rule out other potential causes of anxiety. However, the elevated 24h cortisol level may be contributing to the patient's anxiety symptoms, and this should be taken into consideration when developing a treatment plan.
Given the recent evidence from 1, which provides a strong recommendation for individual or group therapy with treatment options such as CBT, BA, structured physical activity and exercise, or psychosocial interventions with empirically supported components, I would recommend referring the patient to cognitive behavioral therapy (CBT) as a first-line treatment. Additionally, lifestyle modifications including regular exercise (30 minutes of moderate activity 5 times weekly), sleep hygiene practices, caffeine reduction, and mindfulness techniques can be beneficial in managing anxiety symptoms.
It's also important to consider the patient's elevated cortisol level, and while the evidence from 1 is focused on Cushing's disease, it highlights the importance of addressing persistently elevated cortisol levels. In this case, the patient's cortisol level is elevated, but not necessarily indicative of Cushing's disease. However, it's still important to monitor the patient's cortisol level and consider referral to an endocrinologist if the level remains elevated.
While pharmacological approaches, such as SSRIs, may be necessary in some cases, the evidence from 1 and 1 suggests that non-pharmacological approaches should be considered first-line treatments for anxiety. Therefore, I recommend starting with CBT and lifestyle modifications, and monitoring the patient's symptoms and cortisol level closely, before considering pharmacological interventions. Schedule follow-up in 2-4 weeks to assess the patient's response to treatment and adjust the plan as necessary.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Approach to Anxiety Disorder
The patient's symptoms of anxiety worsening over the last few weeks, with normal lab results, including CBC, CMP, TSH, fasting glucose 76, and 24h cortisol 200, suggest that the anxiety disorder is the primary concern.
- The treatment of anxiety disorders should be based on guidelines, meta-analyses, and systematic reviews of randomized controlled studies 2.
- Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both 2.
- Cognitive behavioral therapy (CBT) can be regarded as the psychotherapy with the highest level of evidence 2.
- First-line drugs are the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) 2, 3.
Considerations for Treatment
- When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered 2.
- The patient's cortisol level, which is 200, may not be a significant predictor of psychological therapy response in anxiety disorders 4.
- Both SSRI and CBT treatments have been shown to attenuate insula and amygdala activity during emotion perception, and greater treatment-related decrease in insula and amygdala activity is correlated with greater reduction in anxiety symptoms 5.
Treatment Options
- CBT, pharmacotherapy, and the combination of the two are effective treatments for anxiety disorders 2, 3, 6.
- There is no significant difference between CBT, pharmacotherapy, and the combination of the two in terms of efficacy 6.
- CBT is associated with lower attrition rates compared to pharmacotherapy 6.
- The choice of treatment should be based on the patient's preferences, potential risks, and benefits 6.