What is the most appropriate long-term treatment for Generalized Anxiety Disorder (GAD) in a patient with Hypertension, a Seizure Disorder, and a history of Alcohol Use Disorder?

Sertraline is the Most Appropriate Long-Term Treatment for GAD in This Patient

For this 72-year-old patient with GAD, hypertension, seizure disorder, and alcohol use disorder, sertraline is the most appropriate long-term treatment option.

Rationale for Selecting Sertraline

Sertraline is the optimal choice for this patient due to several key factors:

1. Safety with comorbidities: The patient has multiple comorbidities that influence medication selection:

   • Hypertension: Venlafaxine can increase blood pressure, which is problematic given the patient's current BP of 147/103 mm Hg 1
   • Seizure disorder: Bupropion lowers seizure threshold and is contraindicated
   • Alcohol use disorder: Benzodiazepines like lorazepam are contraindicated due to risk of dependence, respiratory depression, and dangerous interactions with alcohol

2. Efficacy for GAD: SSRIs like sertraline are effective first-line agents for GAD treatment 1

3. Favorable side effect profile: Sertraline has fewer drug interactions and better tolerability in elderly patients compared to alternatives 2

Why Other Options Are Inappropriate

Lorazepam

• Contraindicated with active alcohol use disorder due to:
  • Increased risk of respiratory depression when combined with alcohol
  • High potential for dependence and addiction
  • Not recommended for long-term treatment of GAD 3
  • Risk of falls and cognitive impairment in elderly patients

Bupropion

• Contraindicated in patients with seizure disorders as it lowers seizure threshold
• Not FDA-approved for GAD and has limited evidence for anxiety disorders
• May increase blood pressure

Venlafaxine

• Can cause sustained hypertension, which is problematic given the patient's current elevated blood pressure 1
• The ACC/AHA guidelines specifically note that SNRIs can worsen hypertension 1
• May have more discontinuation symptoms compared to SSRIs 4

Treatment Implementation

1. Starting dose: Begin with 25-50 mg daily of sertraline (lower starting dose for elderly)
2. Titration: Gradually increase by 25-50 mg increments at intervals of at least 1 week as needed
3. Target dose: 50-150 mg daily based on response and tolerability 2
4. Monitoring:
   • Blood pressure regularly
   • Potential drug interactions
   • Suicidal ideation (especially in first few weeks)
   • Electrolytes (risk of hyponatremia in elderly)

Additional Considerations

• Alcohol use: While addressing the alcohol use disorder is important, sertraline is safer than benzodiazepines in patients who continue to drink
• Hypertension management: Consider antihypertensive medications that don't interact with sertraline
• Long-term treatment: GAD often requires long-term treatment, and sertraline has demonstrated efficacy in maintenance therapy 2

Common Pitfalls to Avoid

1. Prescribing benzodiazepines to patients with alcohol use disorder
2. Using SNRIs in patients with uncontrolled hypertension
3. Overlooking seizure risk when selecting psychotropic medications
4. Starting with full doses in elderly patients rather than starting low and titrating slowly

By selecting sertraline, you provide effective treatment for GAD while minimizing risks associated with the patient's multiple comorbidities.