In this post I link to and excerpt from Pharmacotherapy for Generalized Anxiety Disorder in Adults and Pediatric Patients: An Evidence Based Treatment Review [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Expert Opin Pharmacother. 2018 Jul; 19(10): 1057–1070.
Spoiler alert: I didn’t find any particularly useful clinical pearls in this article.
Here are excerpts:
4. Expert opinion
4.1. Synthesis of data
SSRIs are considered to be the first line psychopharmacological interventions in adults with
GAD [17,18], although there is considerable evidence supporting the efficacy and tolerability of SNRIs in these patients as well. The classification of these two medications as first-line interventions is primarily related to the substantial body of evidence supporting their efficacy and, importantly, their tolerability and side effect profile and is consistent with international guidelines [17,18]. Second line interventions in adults with GAD are also supported by numerous randomized controlled trials; however, these medications, which include benzodiazepines, buspirone, SGAs (primarily quetiapine), and some antiepileptic medications (e.g., pregabalin) may be associated with less favorable side effect profiles
relative to antidepressant medications. Third-line interventions include tricyclic antidepressants, which are associated with substantial efficacy but require more monitoring given their clinically-significant, class-related tolerability concerns, which tends to limit their use by non-psychiatrists.
In pediatric patients, SSRIs are considered to be the first line psychopharmacological intervention, and SNRIs may be considered second line. This distinction between SSRIs and SNRIs arise with regard to first and second line treatment stems not from differences in tolerability, but rather from accumulating data suggesting that SSRIs may be associated with greater magnitude of treatment response and a more rapid treatment response compared to SNRIs . In pediatric patients with GAD and related anxiety disorders, SSRIs and SNRIs differ in their response trajectories and magnitude. For SNRIs, the response rate at week 8 was reported to be only 40% of that typically observed for SSRI treatment, and this difference in trajectory was apparent by the second week of treatment. This is of interest in light of three recent meta-analyses of SNRIs and SSRIs in pediatric anxiety disorders [127–129]. These meta-analyses suggest an advantage to SSRIs, compared to SNRIs, and one meta-analysis specifically suggests a relationship between serotonergic selectivity and the
weighted effect size of the antidepressant at endpoint .