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A 43-year-old man with generalized anxiety disorder comes to the clinic for medication. He has taken sertraline in the past but discontinued it because it was œruining his sex life. He then tried gabapentin, which helped somewhat with his anxiety; however, he needed to take high doses, which meant taking many pills during the day, which was œtoo annoying. He is willing to take something œstronger but is scared because of his past experiences. He has no other medical problems and takes no medications at this time. Physical examination is unremarkable. In order to treat his symptoms and avoid the sexual side effects, which of the following is the most appropriate pharmacotherapy?
A. Buspirone
B. Nefazodone
C. Venlafaxine
D. Nortriptyline
E. Paroxetine
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The correct answer is B. Nefazodone is chemically unrelated to SSRIs, tricyclics, tetracyclics, or MAO inhibitors. It has been shown that nefazodone inhibits neuronal uptake of serotonin and norepinephrine. It acts as an antagonist of postsynaptic 5-HTA receptors and of alpha1-adrenergic receptors. It causes no serious cardiovascular side effects, nor is it associated with sexual dysfunction or weight gain. It is approved for treatment of depression and anxiety, but given the strong inhibition of the cytochrome P450 IIIA4 system, caution should be exercised when prescribing other medications.
Buspirone (choice A) is an antianxiety agent that is mostly used only in conjunction with antidepressants for treatment of comorbid depression and anxiety. Decreased libido was associated with its use, but it didn™t affect performance in premarketing trials. It is usually not used as the sole agent of choice.
Venlafaxine (choice C) is a serotonin-norepinephrine reuptake inhibitor. It has no significant interaction with adrenergic, muscarinic, histaminergic, or serotonergic receptors. It can cause anorgasmia and abnormal ejaculation as well as impotence, but its most common side effects are related to increased blood pressure, gastrointestinal symptoms, somnolence, dizziness, nervousness, and dry mouth. It is not officially approved for treatment of PTSD but it is used for treatment of depression.
Nortriptyline (choice D) is a tricyclic antidepressant that affects sexual performance by lowering blood pressure. It is also not the medication of choice for generalized anxiety disorder nowadays.
Paroxetine (choice E) is an SSRI that is approved for treatment of anxiety disorders but does affect sexual performance, especially ejaculation.
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wow nice Q.. thank sshowman
