Maintenance pharmacotherapy for generalised anxiety disorder in adults and young people
Follow the approach to managing generalised anxiety disorder in adults and young people.
If an antidepressant is indicated for generalised anxiety disorder in an adult or young person (if psychosocial interventions are not available, not effective or not preferred, or if symptoms are severe), initial choice should be informed by:
- the drug’s adverse effect profile, potential for drug interactions and safety in overdose
- the patient’s comorbidities
- the patient’s age
- older people are more likely to have multiple comorbidities or be more sensitive to antidepressant adverse effects (eg hyponatraemia with selective serotonin reuptake inhibitors [SSRIs])
- young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with SSRIs. Despite this, SSRIs remain a first-line option when antidepressant therapy is indicated; paroxetine, however, should be avoided because it has been associated with an increased risk of suicidal thoughts and behaviours and other serious adverse events
- the patient’s response to previous treatments and family history of response to treatments
- tolerability when stopping treatment
- whether the patient is planning pregnancy, or is pregnant or breastfeeding (also see Considerations in managing anxiety disorders during the perinatal period).
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) are first-line drugs for the treatment of generalised anxiety disorder. Of the SSRIs, escitalopram has the largest evidence base in generalised anxiety disorder but there are no head-to-head comparisons to show it is more effective than other SSRIs.
Serotonin noradrenaline reuptake inhibitors (SNRIs) (desvenlafaxine, duloxetine, venlafaxine) have high-quality evidence of effect in generalised anxiety disorder and relatively good patient acceptability. Duloxetine may particularly improve anxious thoughts.
If particularly concerned about sensitivity to early adverse effects (eg nausea, restlessness, agitation) of an SSRI or SNRI, consider using a lower starting dose. However, the use of a lower starting dose prolongs the time taken to achieve therapeutic effect. See here for information on managing adverse effects.
Lower doses may be needed in older people; consult a source of drug information.
If an SSRI or SNRI is considered appropriate to treat generalised anxiety disorder, individualise the choice of drug (see above). Use:
1 citalopram 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder (adult) citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder (adult) escitalopram escitalopram escitalopram
OR
1 fluoxetine 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder (adult) fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder (adult) fluvoxamine fluvoxamine fluvoxamine
OR
1 paroxetine 20 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 50 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder paroxetine paroxetine paroxetine
OR
1 sertraline 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder (adult) sertraline sertraline sertraline
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 60 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 120 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing generalised anxiety disorder duloxetine duloxetine duloxetine
OR
2 venlafaxine 75 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 37.5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 375 mg is reached. If there is an acceptable response, continue at the same dose for at least 1 year, then consider deprescribing. generalised anxiety disorder venlafaxine venlafaxine venlafaxine