What is a good adjunct for a patient with uncontrolled anxiety on escitalopram (selective serotonin reuptake inhibitor) 20 mg, with symptoms of irritability and frustration?

From the Guidelines

For a patient with uncontrolled anxiety on escitalopram 20 mg who is experiencing irritability and frustration, adding buspirone would be an appropriate adjunct treatment. Buspirone can be started at 7.5 mg twice daily and gradually increased to 15-30 mg twice daily as tolerated. This medication works as a partial agonist at serotonin 5-HT1A receptors, which complements the mechanism of escitalopram without increasing the risk of serotonin syndrome. Unlike benzodiazepines, buspirone is non-sedating, non-addictive, and doesn't cause withdrawal symptoms, making it suitable for longer-term use. It specifically targets irritability and frustration components of anxiety while having minimal side effects and drug interactions. Patients should be advised that buspirone typically takes 2-4 weeks to show full benefits, and it should be taken consistently rather than as needed. Regular follow-up appointments every 2-4 weeks initially are recommended to monitor response and adjust dosing as necessary.

Key Considerations

• Buspirone is a suitable adjunct treatment for patients with uncontrolled anxiety on escitalopram, as it has a different mechanism of action and minimal side effects 1.
• The starting dose of buspirone is 7.5 mg twice daily, which can be gradually increased to 15-30 mg twice daily as tolerated 1.
• Buspirone is non-sedating, non-addictive, and doesn't cause withdrawal symptoms, making it a good option for longer-term use 1.
• Patients should be advised to take buspirone consistently and to expect full benefits after 2-4 weeks of treatment 1.
• Regular follow-up appointments are necessary to monitor response and adjust dosing as necessary 1.

Alternative Options

• Other medications, such as SNRIs (e.g., venlafaxine, duloxetine), may also be considered as adjunct treatments for anxiety, but buspirone is generally better tolerated and has fewer side effects 1.
• Benzodiazepines may be used for short-term relief of anxiety symptoms, but they are not recommended for longer-term use due to the risk of dependence and withdrawal symptoms 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Adjunct Therapy Options for Uncontrolled Anxiety on Escitalopram

• Considering the patient's symptoms of irritability and frustration while on escitalopram 20 mg, an adjunct therapy may be necessary to achieve better control of anxiety symptoms.
• According to 2, several classes of drugs, including benzodiazepines, azapirones, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, antihistamines, alpha(2)delta Ca++ channel modulators, and atypical antipsychotics, are consistently beneficial in patients with generalized anxiety disorder (GAD).
• Cognitive therapy is also effective as a first-line treatment for GAD, as mentioned in 2, and combining selective serotonin reuptake inhibitors with cognitive behavioral therapy (CBT) has been shown to produce greater improvement than either treatment alone in youth with depression and anxiety 3.

Potential Adjunct Therapies

• Benzodiazepines: may be considered as an adjunct therapy for short-term use, but their potential for dependence and withdrawal symptoms should be carefully weighed 2.
• Azapirones: such as buspirone, may be an alternative adjunct therapy option, but their efficacy and potential interactions with escitalopram should be considered 2.
• Cognitive Behavioral Therapy (CBT): as an adjunct to escitalopram, CBT may help improve symptoms of anxiety and depression, especially in patients who have not responded adequately to pharmacotherapy alone 3.

Considerations for Adjunct Therapy

• The patient's comorbid conditions, such as depression, should be taken into account when selecting an adjunct therapy, as certain medications or therapies may be more effective for specific conditions 2, 4.
• The potential side effects and interactions of the adjunct therapy with escitalopram should be carefully evaluated to minimize risks and optimize benefits 4, 5.
• Regular monitoring of the patient's symptoms and response to treatment is essential to adjust the treatment plan as needed and ensure the best possible outcomes 6.