What are the treatment options for a patient with prominent anxiety and comorbid depression, currently on levothyroxine and Eliquis (apixaban)?

Treatment Options for Anxiety and Depression in a Patient on Levothyroxine and Eliquis

For a patient with prominent anxiety and comorbid depression who is on levothyroxine and Eliquis (apixaban), sertraline is the recommended first-line treatment due to its extensive safety profile in cardiovascular patients and effectiveness for both anxiety and depression.

First-Line Pharmacotherapy

• Selective Serotonin Reuptake Inhibitors (SSRIs) are well-studied in people with cardiovascular disease and appear to be safe, though their efficacy in treating comorbid depression and anxiety shows mixed results 1
• Among SSRIs, sertraline has been studied extensively and appears to have a lower risk of QTc prolongation than citalopram or escitalopram, making it particularly suitable for patients on anticoagulants like Eliquis 1
• Patients on levothyroxine are more likely to have anxiety (OR = 2.08) and depression (OR = 3.13) despite treatment, indicating the need for additional psychiatric intervention 2

Medications to Avoid

• Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) have significant cardiovascular side effects, including hypertension, hypotension, and arrhythmias, and should be avoided 1
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) may cause hypertension at high doses and should be used with caution in patients with cardiovascular concerns 1
• Anticonvulsants such as gabapentin and pregabalin require renal dose adjustment and typically aren't recommended due to risk of fluid retention, weight gain, and heart failure exacerbation 1

Alternative Pharmacologic Options

• Mirtazapine has been shown to be safe in cardiovascular patients and offers additional benefits including appetite stimulation and sleep improvement, though its efficacy in treating depression in cardiovascular disease patients hasn't been fully assessed 1
• Trazodone may be considered for patients with prominent insomnia symptoms, as it has shown improvement in sleep scores compared to other antidepressants 1
• Bupropion has a significantly lower rate of sexual adverse events than fluoxetine or sertraline, which may be important for quality of life considerations 1

Non-Pharmacologic Approaches

• Cognitive behavioral therapy (CBT) is recommended as first-line treatment for insomnia before initiating sedating antidepressants 1
• For patients with both depression and anxiety, treatment of depressive symptoms should be prioritized, or alternatively, treatment with a unified protocol (combining CBT treatments for depression and anxiety) may be used 1
• Psychological and psychosocial interventions should derive from manualized, empirically supported treatments 1

Monitoring and Follow-up

• Patients should be regularly assessed for treatment response, beginning within 1-2 weeks of initiation of therapy 1
• If pharmacologic treatment is used, the treating clinician should regularly (at 4 and 8 weeks) assess symptom relief, side effects, and patient satisfaction using standardized validated instruments 1
• After 8 weeks of treatment, if there is little improvement in symptoms despite good adherence, the treatment regimen should be adjusted (e.g., add a psychological intervention to pharmacotherapy, change medication, or refer to individual therapy if group therapy was initially used) 1

Special Considerations for This Patient

• The presence of levothyroxine treatment suggests thyroid dysfunction, which can exacerbate mood disorders even when treated 2
• Eliquis (apixaban) necessitates careful consideration of drug interactions and bleeding risk, making SSRIs with lower interaction potential preferable 1
• Patients with hypothyroidism may have persistent anxiety and depression despite levothyroxine treatment, indicating the need for dedicated psychiatric treatment 2, 3

Treatment Algorithm

1. Start with sertraline (initial dose 25-50mg daily, titrate as needed) as first-line treatment 1
2. If insomnia is prominent, consider adding trazodone at bedtime or switching to mirtazapine 1
3. If response is inadequate after 8 weeks of optimized treatment, consider:
   • Adding CBT if not already implemented 1
   • Switching to another SSRI (except citalopram or escitalopram due to QTc concerns) 1
   • Consider mirtazapine if appetite stimulation is also needed 1
4. Monitor for treatment response every 1-2 weeks initially, then at 4 and 8 weeks 1