Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
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- Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
PLS EXPLAIN WHY U CHOSE ONE DRUG OVER ANOTHER. LOST ALOT OF POINTS ON THAT THE LAST TIME
//
Generalized Anxiety Disorder
Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
Decision Point One
Begin Zoloft 50 mg orally daily
RESULTS OF DECISION POINT ONE
-
-
-
- Client returns to clinic in four weeks
- Client informs you that he has no tightness in chest, or shortness of breath
- Client states that he noticed decreased worries about work over the past 4 or 5 days
- HAM-A score has decreased to 18 (partial response)
Decision Point Two
Select what the PMHNP should do next:
Increase dose to 75 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client reports an even further reduction in his symptoms
- HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Start Over
Increase current dose of medication to 100 mg orally daily
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Start Over
Add augmentation agent such as BuSpar (buspirone)
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
Start Over
Increase dose to 100 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client is a bit evasive about his symptoms. Eventually he admits that he stopped taking the medication about a week ago because he was experiencing difficulty acquiring an erection.
Decision Point Three
Select what the PMHNP should do next:
Start Paxil (paroxetine) at 50 mg orally daily
Guidance to Student
The PMHNP should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. The PMHNP should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, the PMHNP could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
Start Over
Add agent to treat side effects
Guidance to Student
The PMHNP should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. The PMHNP should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, the PMHNP could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
Start Over
Begin Lexapro (escitalopram) 5 mg orally daily
Guidance to Student
The PMHNP should decrease dose to 50 mg po daily X 7 days, then attempt re-challenging the client with a trial of 75 mg po daily. Erectile dysfunction with SSRIs may be dose dependent, and may resolve with the passage of time. The PMHNP should discuss this course of action with the client and determine whether or not he is interested in attempting a re-challenge of the drug. If the symptom persists, discuss other treatment options with client- such as Lexapro- although Lexapro is an SSRI, not all clients will experience the same side effects to different medications in the class. If the client is having a good response, but continues to demonstrate difficulties with erection, the PMHNP could consider the addition of Bupropion, and if indicated, a phosphodiesterase-5 inhibitor such as Viagara. This would have to be used with caution in consideration of the clients HTN.
Start Over
No change in drug/dose at this time
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client reports no further decreases in anxiety and is wondering if this means that the medication will not be effective for him
Decision Point Three
Select what the PMHNP should do next:
Increase drug to 75 mg po daily
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.
Start Over
Consider addition of augmentation agent such as BuSpar (buspirone)
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.
Start Over
Switch to a serotonin norepinephrine reuptake inhibitor (SNRI) such as Effexor (venlafaxine)
Guidance to Student
Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.
Start Over
//
Generalized Anxiety Disorder
Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
Decision Point One
Begin Tofranil (imipramine) 25 mg orally BID
RESULTS OF DECISION POINT ONE
-
-
-
- Client returns to clinic in four weeks
- Client reports a “slight” decrease in symptoms
- Client’s states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath
- HAM-A score decreased from 26 to 22
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.
Start Over
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.
Start Over
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.
Start Over
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).
Start Over
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).
Start Over
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).
Start Over
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.
Start Over
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.
Start Over
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.
Start Over
//
Generalized Anxiety Disorder
Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
Decision Point One
Begin Buspirone 10 mg orally BID
RESULTS OF DECISION POINT ONE
-
-
-
- Client returns to clinic in four weeks
- Client reports slight decrease in symptoms
- Client states that he still feels very anxious
- HAM-A score decreased from 26 to 23
Decision Point Two
Select what the PMHNP should do next:
Increase buspirone to 10 mg orally TID
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client reports no change in his anxiety
- HAM-A score has decreased from 23 to 22
Decision Point Three
Select what the PMHNP should do next:
Continue current dose and reassess in 4 more weeks
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.
Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Start Over
Augment with Ativan (lorazepam) 0.5 mg orally TID
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.
Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Start Over
Discontinue buspirone and begin Zoloft 50 mg orally daily
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, the PMHNP can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.
Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. The PMHNP should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
Start Over
Increase buspirone to 20 mg orally TID
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client reports nausea, dizziness, nervousness, headaches, and dry mouth
- HAM-A score reveals no change and he reports that he still feels anxious
Decision Point Three
Select what the PMHNP should do next:
Decrease BuSpar to 15 mg orally TID
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.
It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.
The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Start Over
Explain to the client that these are normal side effects of buspirone and maintain current dose for another 4 weeks
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.
It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.
The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Start Over
Discontinue buspirone and begin Zoloft 50 mg orally daily
Guidance to Student
It is apparent that the higher dose of buspirone was successful only in causing side effects and offered minimal therapeutic benefit to the client. Decreasing buspirone to 15 mg orally TID may alleviate some of the side effects, but would also likely result in decreased therapeutic effect (which in this case was minimal). The goal of therapy is to treat the client’s anxiety- not just alleviate side effects.
It would not be appropriate to explain to the client that these are “normal side effects” and continue the same dose with a plan to reassess in 4 weeks. Recall that the onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work at all.
The buspirone at this point meets the criteria for treatment failure (as it failed to result in at least a 25% decrease in symptoms), thus it would be appropriate to discontinue and begin a first line agent such as an SSIR (like Zoloft 50 mg orally daily) at this point.
Start Over
Discontinue buspirone and begin Lexapro 10 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
- Client reports that he feels “great”
- Client states that his anxiety is getting “better”
- HAM-A score has decreased from 23 to 13
- Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon
Decision Point Three
Select what the PMHNP should do next:
Increase Lexapro to 15 mg orally daily in AM
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.
At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
Start Over
Continue same dose of Lexapro but change administration time to bedtime
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.
At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
Start Over
Re-start BuSpar at 10 mg orally TID
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.
At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
Start Over
