What is the best approach for managing worsening anxiety in a patient taking escitalopram (20mg/day), amitriptyline (20mg at hour of sleep (HS) for pain) and PRN (as needed) lorazepam (Ativan) (1mg orally disintegrating tablet (ODT))?

Management of Worsening Anxiety Despite Current Medication Regimen

For patients experiencing worsening anxiety despite taking escitalopram 20mg/day, amitriptyline 20mg at bedtime, and PRN lorazepam 1mg ODT, the most effective approach is to optimize lorazepam usage for short-term management while considering augmentation strategies or medication adjustments for long-term control.

Current Medication Analysis

• Escitalopram 20mg/day is already at the maximum recommended dose for anxiety disorders 1, limiting options for dose escalation
• Amitriptyline 20mg at bedtime is being used for pain management rather than as a primary anxiolytic 2
• PRN lorazepam 1mg ODT is appropriate for acute anxiety management but may not provide consistent control if used irregularly 2

Short-Term Management Options

• Optimize lorazepam usage with a more structured schedule (0.5-1mg orally up to four times daily as needed) for temporary anxiety control 2
• Consider switching from PRN to scheduled lorazepam temporarily while implementing long-term strategies 2
• Be cautious about benzodiazepine dependence with regular use, as tolerance and addiction can develop 2

Long-Term Management Strategies

Option 1: Medication Augmentation

• Consider adding a medication with a different mechanism of action:
  • Pregabalin has demonstrated efficacy for anxiety disorders with a favorable side effect profile 3
  • Buspirone could be added as it works through different mechanisms than SSRIs and has minimal addiction potential 3

Option 2: Medication Switch

• If escitalopram is not providing adequate relief despite maximum dosing, consider switching to:
  • Venlafaxine (an SNRI) which has demonstrated efficacy in treatment-resistant anxiety 4
  • Paroxetine, which may be more effective for some patients with anxiety disorders 5

Option 3: Combination Therapy

• Add cognitive behavioral therapy (CBT), which has strong evidence for anxiety management and can enhance medication effects 6, 3
• Consider a structured anxiety management program including relaxation techniques, breathing exercises, and stress management 2

Implementation Plan

1. First visit: Optimize lorazepam usage temporarily while initiating one of the long-term strategies 2
2. Follow-up in 2 weeks: Assess response to initial intervention 7
3. Follow-up in 4-6 weeks: Evaluate effectiveness of the chosen long-term strategy and adjust as needed 3

Monitoring and Precautions

• Monitor for signs of benzodiazepine dependence if using lorazepam regularly (tolerance, withdrawal symptoms between doses) 2
• Watch for potential drug interactions, particularly between multiple psychotropic medications 7
• Assess for serotonin syndrome symptoms if adding another serotonergic agent 1
• Regular follow-up is essential to evaluate treatment response and adjust the regimen as needed 3

Common Pitfalls to Avoid

• Continuing ineffective medication without adjustment - if escitalopram is not working at 20mg, a different approach is needed 6
• Relying solely on PRN benzodiazepines for chronic anxiety management 2, 3
• Overlooking the importance of non-pharmacological interventions like CBT 6, 3
• Failing to address potential underlying causes of worsening anxiety (sleep disturbances, pain, substance use) 2