What are the recommendations for acute anxiety relief in a patient on a complex regimen including Mirtazapine, Zopiclone (Imovane), Lamotrigine, Clonazepam, Brexpiprazole, Melatonin (Circadin), Pregabalin (Lyrica), and Tapentadol (Palexia)?

Acute Anxiety Management in a Patient on Complex Polypharmacy

For acute anxiety relief in a patient on this complex medication regimen, use a benzodiazepine (lorazepam or midazolam) as effective monotherapy, avoiding additional clonazepam due to existing use. 1

Assessment of Current Medication Regimen

The patient is currently taking:

• Mirtazapine 45mg (antidepressant)
• Zopiclone (Imovane) 7.5mg at night (non-benzodiazepine hypnotic)
• Lamotrigine 200mg at night (mood stabilizer)
• Clonazepam 0.5mg twice daily (benzodiazepine)
• Brexpiprazole 3mg daily (atypical antipsychotic)
• Melatonin (Circadin) 2mg daily (sleep aid)
• Pregabalin (Lyrica) 225mg twice daily (anticonvulsant/anxiolytic)
• Tapentadol (Palexia) 200mg twice daily (opioid analgesic)

Pharmacological Management Options

First-line Approach

• Lorazepam is recommended for acute anxiety management in this patient 1
  • Benefits: Rapid onset, effective for acute anxiety
  • Caution: Patient is already on clonazepam, so monitor closely for excessive sedation
  • Dosing: Consider starting with 0.5-1mg orally for acute episodes

Alternative Options

1. Midazolam can be considered if more rapid sedation is required 1

   • Particularly useful if parenteral administration is needed
   • Shorter half-life than lorazepam

2. Avoid adding another antipsychotic as the patient is already on brexpiprazole

   • Adding another antipsychotic could increase risk of side effects without additional benefit

3. Avoid additional pregabalin despite its anxiolytic properties 2

   • Patient is already on a substantial dose (225mg twice daily)
   • Increasing the dose could lead to excessive sedation when combined with other CNS depressants

Important Considerations and Precautions

Drug Interactions

• This patient is on multiple CNS depressants (clonazepam, zopiclone, pregabalin, tapentadol)
• Risk of excessive sedation, respiratory depression, and cognitive impairment
• Start with lower doses of any additional benzodiazepines

Monitoring

• Assess level of sedation frequently
• Monitor respiratory status
• Evaluate for cognitive impairment
• Watch for paradoxical reactions (increased agitation)

Long-term Considerations

• Acute anxiety management should be brief
• After stabilization, consider reviewing the entire medication regimen
• SSRIs or SNRIs may be more appropriate for long-term anxiety management 3, 4
• Cognitive behavioral therapy should be considered as an adjunct treatment 3

Pitfalls to Avoid

• Avoid long-term addition of another benzodiazepine beyond acute management
• Do not abruptly discontinue any current medications, especially clonazepam
• Avoid prescribing medications with similar mechanisms of action that could compound side effects
• Be cautious about potential serotonin syndrome with this complex regimen

Follow-up Plan

• Reassess within 24-48 hours after acute intervention
• Consider medication reconciliation to simplify regimen if possible
• Evaluate for underlying causes of anxiety exacerbation
• Consider non-pharmacological interventions for anxiety management