Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Middle age male

 

Decision Point One


Begin Tofranil (imipramine) 25 mg orally BID

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Increase Tofranil to 50 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode.
Decision Point Three
Select what the PMHNP should do next:


Restart Tofranil at 25 mg orally BID
Guidance to Student
At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.
Discontinue Tofranil and begin SSRI
Guidance to Student
At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.
Discontinue Tofranil and begin BuSpar at 5 mg orally TID
Guidance to Student
At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.
Continue current dose and reassess in 4 weeks

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that he has had no change in his level of anxiety
  • Client reports that his anxiety may be getting a bit “worse” because he has been having the strange bouts of dizziness
Decision Point Three
Select what the PMHNP should do next:


Increase Tofranil to 50 mg orally BID
Guidance to Student
Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous.

Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.

While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.

Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).
Explain that the dizziness will pass and maintain current dose until next appointment
Guidance to Student
Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous.

Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.

While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.

Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).
Discontinue Tofranil and begin Lexapro 5 mg orally daily for 7 days, then increase to 10 mg orally daily until next appointment
Guidance to Student
Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous.

Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.

While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.

Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).
Add an augmentation agent such as BuSpar (buspirone) 5 mg orally TID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that symptoms are pretty much unchanged”
  • HAM-A score decreased from 22 to 19. He is still troubled by dizziness
Decision Point Three
Select what the PMHNP should do next:


Increase Tofranil to 75 mg orally BID
Guidance to Student
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effects has not gone away is probably concerning to the client and may impact his quality of life.

Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.

At this point, the PMHNP can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for the PMHNP to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.
Increase BuSpar to 10 mg orally TID
Guidance to Student
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effects has not gone away is probably concerning to the client and may impact his quality of life.

Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.

At this point, the PMHNP can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for the PMHNP to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.
Discontinue Tofranil and BuSpar and begin Paxil 20 mg orally daily
Guidance to Student
Increasing Imipramine may result in an increase in side effects which the client is troubled by (dizziness). The fact that the side effects has not gone away is probably concerning to the client and may impact his quality of life.

Increasing the BuSpar may be appropriate, but again, BuSpar is a second-line agent and the client has not had an adequate trial of therapy with a first line agent.

At this point, the PMHNP can see where the client is on two medications- neither of which is a first line agent for treatment of generalized anxiety disorder. The most prudent course of action would be for the PMHNP to discontinue Imipramine and BuSpar and begin an SSRI such as Paxil. The client should return to clinic in 4 weeks for an evaluation of symptoms after this change is made.