What alternative treatments can be considered for a patient with post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) who has inadequate anxiety control despite Zoloft (sertraline) 200mg and Prazosin 1mg qHS, and has failed Buspar (buspirone), with physical symptoms including tremors and tachycardia, and has a contraindication to propranolol due to asthma?

From the Guidelines

For a patient with PTSD, MDD, and GAD on suboxone treatment who has persistent anxiety despite Zoloft 200mg and Prazosin 1mg, I would recommend considering hydroxyzine 25-50mg TID PRN as a first option. This antihistamine has anxiolytic properties without respiratory depression risks that would complicate her asthma or suboxone therapy 1. If hydroxyzine provides insufficient relief, pregabalin (Lyrica) starting at 75mg BID and titrating up to 300mg daily in divided doses could be effective, as it works through calcium channel modulation rather than affecting respiratory drive. Alternatively, mirtazapine 15-30mg at bedtime might help with both anxiety and sleep while potentially augmenting the antidepressant effect of Zoloft. Given her asthma, beta-blockers like propranolol are contraindicated, and benzodiazepines should be avoided due to respiratory depression risks when combined with suboxone.

Some key points to consider in managing this patient's anxiety include:

• Regular monitoring for side effects and therapeutic response is essential, with dose adjustments as needed 1.
• Non-pharmacological approaches including CBT, mindfulness training, and breathing exercises should be incorporated into her treatment plan.
• The patient's treatment plan should be reassessed regularly to determine whether the first course of treatment for anxiety is effective, or if not, what timely treatment modifications can be implemented 1.
• Screening and early, efficacious treatment for those manifesting significant symptoms of anxiety hold the potential to reduce the human cost of cancer and other chronic conditions, not only for patients but also for those who care for and about them 1.

It's also important to note that some studies have shown that medication treatment for anxiety can be effective, with SSRI medications such as fluoxetine, sertraline, and paroxetine being more effective than placebo in the treatment of PTSD 1. However, the choice of treatment should be based on factors such as treatment availability, feasibility, and patient preference 1.

From the Research

Treatment Options for Anxiety

The patient's anxiety remains high despite being on a medication regimen that includes Zoloft 200mg for depression and Prazosin 1mg qHS for nightmares. Considering the patient's asthma, propranolol is not a viable option.

• Hydroxyzine, an anti-histamine medication, has been studied as a treatment option for generalized anxiety disorder (GAD) 2.
• The study found that hydroxyzine is more effective than placebo for GAD and is also acceptable and tolerable.
• However, the study notes that the included studies had a high risk of bias, and the small number of studies and overall small sample size limit the recommendation of hydroxyzine as a reliable first-line treatment in GAD.

Buspirone as a Treatment Option

Buspirone has been studied as a treatment option for anxiety, including GAD and posttraumatic stress disorder (PTSD) 3, 4, 5, 6.

• Buspirone has been found to be effective in treating generalized anxiety, but not other anxiety disorders 3.
• A study found that buspirone may be effective in alleviating the symptoms of PTSD, with 7 out of 8 patients exhibiting a significant reduction in symptoms 4.
• Another study found that buspirone is effective in the treatment of anxiety with efficacy and dosage comparable to diazepam or chlorazepate 5.
• A meta-analysis of eight randomized, controlled studies found that buspirone produced significant improvement over baseline in total Hamilton Anxiety (HAM-A) scores compared to patients who received placebo, and that patients with GAD and coexisting depressive symptoms exhibited significantly greater improvement with buspirone compared to placebo treatment 6.

Considerations for Treatment

Given the patient's history of not responding to buspar, it may be necessary to consider alternative treatment options, such as hydroxyzine or other anxiolytic agents.

• The patient's physical symptoms, such as tremors and racing heart, should also be taken into consideration when selecting a treatment option.
• Further evaluation and monitoring of the patient's response to treatment may be necessary to determine the most effective treatment plan.