Anxiety

Description

General Measures

Medicine Treatment

Referral

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F41.0-3/F41.8-9/ + (Z51.5)

See: Anxiety Disorders

DESCRIPTION

Some symptoms of anxiety in palliative care patients may be expected, given the concerns of living with a serious illness. However, if the symptoms are debilitating, they require treatment.

GENERAL MEASURES

Address any contributing factors such as pain and dyspnoea.
Consider other underlying conditions that may mimic anxiety e.g. electrolyte imbalance, hyperthyroidism, hypoxia, arrhythmias and many adverse drug reactions.
Assess for depression.
Offer referral for psychotherapy if available.

MEDICINE TREATMENT

Adult: 

• Fluoxetine, oral.
  • Initiate at 20 mg alternate days for 2 weeks.
  • Increase to 20 mg daily after 2–4 weeks.
  • Delay dosage increase if increased agitation/panicky feelings occur.

LoE:IIb⁸

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CAUTION FLUOXETINE

Fluoxetine is contraindicated if eGFR < 10 mL/min

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LoE:IVb⁹

OR

If fluoxetine is poorly tolerated:

• Alternative SSRI e.g.: 
• Citalopram, oral.
  • Initiate at 10 mg daily for 2 weeks.
  • Then increase to 20 mg daily.

LoE:IIb¹⁰

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Note:

Effects of SSRIs are only apparent after 2–3 weeks of treatment, so they should be reserved for patients where end-of-life is not imminent.

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For acute anxiety reactions:

• Benzodiazepine, e.g.: 
• Diazepam, oral, 2.5–5 mg.
  • For a maximum of 10 days.

LoE:IIb¹¹

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Note:

Benzodiazepines might cause sedation and confusion. Use with caution. 

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CAUTION - BENZODIAZEPINES: Associated with cognitive impairment – reversible with short-term use and irreversible with long-term use. Elderly are at risk of over-sedation, falls and hip fractures. Dependence may occur after only a few weeks of treatment. Prescribe for as short a period of time as possible. Warn patient not to drive or operate machinery when used short-term. Avoid use in people at high risk of addiction – personality disorders and those with previous or other substance misuse. LoE:IIIb12

REFERRAL

• All children

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024

Chapter 22: Medicines Used in Palliative Care_22.2 Neuropsychiatric Conditions_22.2.1 Anxiety