What is the best management plan for a patient with generalized anxiety disorder, panic attacks, and possible sleep apnea, currently taking bupropion (Bupropion) XL, lorazepam (Ativan), gabapentin, prometrium, and an estradiol patch?

Management Plan for Generalized Anxiety Disorder with Panic Attacks and Possible Sleep Apnea

Continue bupropion XL 150 mg BID as the primary antidepressant, initiate an SSRI (sertraline 25-50 mg daily or escitalopram 10 mg daily) for anxiety control, maintain gabapentin with upward titration to 300 mg BID, begin tapering lorazepam once SSRI reaches therapeutic effect, and proceed with sleep study referral urgently. 1

Immediate Pharmacological Adjustments

SSRI Initiation (Priority Action)

• Start sertraline 25-50 mg daily or escitalopram 10 mg daily as first-line treatment for generalized anxiety disorder and panic attacks 1
• Sertraline and escitalopram are preferred because they have weight-neutral profiles with long-term use, lower discontinuation syndrome risk compared to paroxetine, and fewer drug-drug interactions than fluvoxamine 1
• Increase dose every 1-2 weeks as tolerated until therapeutic benefit achieved (sertraline up to 200 mg/day, escitalopram up to 20 mg/day) 1
• Warn patient that initial adverse effects may include transient anxiety or agitation in first 1-2 weeks; starting with subtherapeutic "test dose" minimizes this risk 1

Bupropion Management

• Continue bupropion XL 150 mg BID (current total 300 mg/day) 2
• Bupropion is activating and can exacerbate anxiety, but discontinuation risks worsening depression 1, 2
• Monitor closely for increased anxiety, agitation, or insomnia—if these worsen significantly after SSRI initiation, consider reducing bupropion to 150 mg daily 2
• The maximum dose of 300 mg/day should not be exceeded due to seizure risk 2
• Advise taking second dose before 3 PM to minimize insomnia 1

Gabapentin Optimization

• Increase gabapentin to 300 mg BID (morning and afternoon dosing) 1, 3
• Gabapentin demonstrates clear dose-response pattern for generalized anxiety disorder symptoms 3
• Can further titrate to 300 mg TID if needed for symptom control, though BID dosing may suffice 3
• This medication addresses both anxiety and potential neuropathic pain components 1, 4

Benzodiazepine Tapering Strategy

• Begin lorazepam taper once SSRI reaches therapeutic dose (4-6 weeks) 1
• Reduce lorazepam by 0.25 mg every 1-2 weeks to avoid withdrawal symptoms and rebound anxiety 1
• Benzodiazepines should be avoided for long-term anxiety management due to tolerance, dependence, and cognitive impairment risks, especially given her age (approaching older adult category) 1
• Maintain PRN availability during taper but encourage use of breathing exercises and gabapentin for breakthrough symptoms 1

Sleep Disorder Evaluation (Urgent Priority)

Sleep Study Referral

• Order polysomnography immediately given snoring, nocturnal awakenings, and BMI 27.6 kg/m² (overweight status increases obstructive sleep apnea risk) 1
• Sleep apnea significantly exacerbates anxiety symptoms and treatment resistance 1
• If OSA confirmed, initiate CPAP or BiPAP therapy—this alone may substantially improve anxiety and panic symptoms 1

Sleep Hygiene Pharmacological Support

• Add mirtazapine 7.5-15 mg at bedtime if insomnia persists after 4 weeks of SSRI therapy and sleep study is pending or negative for OSA 1
• Mirtazapine is particularly effective when depression, anxiety, anorexia, and insomnia coexist 1
• Alternative: trazodone 25-50 mg at bedtime, though mirtazapine preferred given reduced appetite 1
• Avoid zolpidem given next-morning impairment risks and her need for daytime alertness 1

Cardiovascular and Metabolic Monitoring

Lipid Management

• Initiate statin therapy now given mixed hyperlipidemia (elevated total cholesterol, LDL, triglycerides; low HDL) and family history of myocardial infarction 1
• Sertraline is weight-neutral long-term, which supports metabolic goals 1
• Repeat lipid panel in 3 months after statin initiation, not 3-6 months as initially planned 1

Liver Function Monitoring

• Mild ALP and GGT elevation requires monitoring, especially with multiple medications 1
• Repeat liver enzymes in 3 months; if worsening occurs, consider duloxetine avoidance (hepatotoxicity risk) and evaluate other causes 1

Psychosocial Interventions (Essential Adjunct)

Cognitive Behavioral Therapy

• Refer for individual CBT specifically designed for generalized anxiety disorder and panic disorder (12-14 sessions over 3-4 months) 1
• CBT combined with SSRI shows superior outcomes compared to either treatment alone for anxiety disorders 1
• CBT facilitates benzodiazepine discontinuation and prevents relapse 1

Caregiver Stress Management

• Contact husband's dermatology team immediately to optimize his pruritus management—this is a modifiable stressor directly triggering her panic attacks 1
• Refer to caregiver support resources and respite care options 1
• Structured relaxation training and mindfulness-based stress reduction specifically target autonomic arousal associated with chronic pain and anxiety 1

Monitoring Schedule

Week 2-4 Follow-up

• Assess SSRI tolerability, side effects (especially activation, GI symptoms, sexual dysfunction) 1
• Monitor for suicidal ideation, behavioral activation, agitation—particularly in first month of SSRI therapy 1, 2
• Evaluate gabapentin response and titrate as needed 3

Week 6-8 Follow-up

• Assess anxiety symptom reduction using standardized scales (GAD-7, PDSS) 1
• If inadequate response, increase SSRI dose or consider switching to venlafaxine XR 37.5-75 mg daily (SNRI alternative) 1
• Begin lorazepam taper if SSRI showing benefit 1

Month 3 Follow-up

• Repeat lipid panel and liver enzymes 1
• Reassess need for mirtazapine or other sleep aids based on sleep study results 1
• Evaluate for SSRI dose optimization or augmentation strategies if partial response 1

Critical Safety Considerations

Seizure Risk Monitoring

• Bupropion lowers seizure threshold; avoid exceeding 300 mg/day total dose 2
• Caution with rapid benzodiazepine discontinuation (increases seizure risk with bupropion) 2
• Avoid alcohol and ensure adequate sleep (sleep deprivation increases seizure risk) 2

Serotonin Syndrome Prevention

• Monitor for serotonin syndrome when combining SSRI with other serotonergic agents (though current regimen low-risk) 1
• Symptoms include agitation, confusion, tremor, hyperthermia, hyperreflexia—requires immediate discontinuation 1

Angle-Closure Glaucoma Screening

• Bupropion can cause mild pupillary dilation; if patient has narrow angles or family history of glaucoma, refer for ophthalmologic evaluation 2

Treatment-Resistant Scenarios

If Inadequate Response at 8-12 Weeks

• Switch to different SSRI (escitalopram if started sertraline, or vice versa) 1
• Alternative: switch to venlafaxine XR 75-225 mg daily (SNRI with evidence for anxiety with depression) 1
• Consider augmentation with continued gabapentin and optimize to 300 mg TID 3
• Duloxetine avoided given liver enzyme elevations 1

Combination Therapy Considerations

• If partial SSRI response, add mirtazapine 15-30 mg at bedtime for augmentation (addresses insomnia, anxiety, appetite) 1
• Pregabalin 150-600 mg/day is alternative to gabapentin if inadequate response, though gabapentin preferred initially given lower cost 4

1, 2, 4, 3