Answer

Belling’s Case Study

            Belling should be considered for Zoloft (sertraline), Xanax (alprazolam), Ativan (lorazepam), and Lexapro (escitalopram oxalate) for management of depression and anxiety associated with obsessive compulsive disorder (Prescribers’ Digital Reference (PDR), 2021_a, _{b, c, d}). Sertraline is a selective serotonin reuptake inhibitor antidepressant (SSRI) indicated for obsessive compulsive disorder, depression, post-traumatic stress disorder, panic disorder, premenstrual dysphoric disorder, and social anxiety disorder (PDR, 2021_a). On the other hand, alprazolam is an anxiolytic or a benzodiazepine indicated for panic disorder and anxiety (PDR, 2021_b). Lorazepam is classified as an anticonvulsant, benzodiazepine as well as an anxiolytic indicated for anxiety, insomnia, and status epilepticus (PDR, 2021_c). Lastly, escitalopram oxalate is an SSRIs indicated for generalized anxiety disorder and major depression (PDR, 2021_d).

Caution should be observed since sertraline can increase suicidal tendencies at the early stages. Liver function test is necessary since sertraline is not recommended in patients with moderate to severe hepatic impairment (PDR, 2021_a). Boxed warning for administration of alprazolam indicate that the drug should be avoided in patients with pulmonary disease, chronic obstructive disease (COPD), respiratory depression, coadministration with other central nervous system (CNS) depressants, and/or those with sleep apnea. Liver function test should be performed. Alprazolam dosage should be lowered in case of hepatic impairment (PDR, 2021_b). Boxed warning for lorazepam includes COPD, congenital heart disease, pulmonary hypertension, respiratory insufficiency, status asthmaticus, sleep apnea, CNS depression, and coadministration with other CNS depressants (PDR, 2021_c). Escitalopram oxalate should not be used in children since it can cause growth inhibition and should be avoided in patients with existing suicidal ideation (PDR, 2021_d).

Sertraline is contraindicated in patients with hypersensitivity to the drug and should not be used concomitantly with monoamine oxidase inhibitors (PDR, 2021_a). Alprazolam is contraindicated in case of benzodiazepine hypersensitivity, closed-angle glaucoma, Parkinson’s disease, myasthenia gravis, and porphyria (PDR, 2021_b). Similarly, lorazepam is contraindicated in case of benzodiazepine hypersensitivity, benzyl alcohol hypersensitivity, bipolar disorder, depression, suicidal ideation, psychosis, and status epilepticus (PDR, 2021_c). Similarly, liver function test is also recommended before administration of escitalopram oxalate for appropriate dose adjustments (PDR, 2021_d).

Sertraline can cause adverse effects such as organism dysfunction, photosensitivity, menstrual irregularity, insomnia, QT prolongation, confusion, bone fractures, hepatic failure, gastrointestinal bleeding, suicidal ideation, coma, libido decrease and seizures (PDR, 2021_a). Similarly, alprazolam can cause side effects such as seizures, memory impairment, depression, depression, amnesia, dysuria, dyspnea, jaundice, hallucinations, and libido increase (PDR, 2021_b). Lorazepam causes side effects such as coma, pneumothorax, suicidal ideation, cystitis, memory impairment, respiratory depression, and organism dysfunction (PDR, 2021_c). Escitalopram oxalate side effects include suicidal ideation, heart failure, stroke, impotence, depression, priapism, menstrual irregularity, and organism dysfunction (PDR, 2021_d).

Alprazolam, anxiolytic/benzodiazepine, which is indicated for panic disorder and anxiety, is hereby recommended for Belling. The rationale for choice is that the other three drug cause orgasm dysfunction or decreased libido while alprazolam can help increase Billing’s libido (PDR, 2021_b). She is currently complaining of decreased libido, which can be corrected by the drug. Initial dose is 0.25mg to 0.5mg PO three times per day. The dose can be increased gradually as tolerated at intervals of 3 – 4 days to maximum dose of 4 mg per day in divided doses. Tapering schedule include reduce by no more then 0.5mg per three days to avoid withdrawal symptoms (PDR, 2021_b). Alprazolam acts the level of the thalamic, limbic, and hypothalamic regions of the CNS. It can produce CNS depression required for hypnosis, sedation, anticonvulsant activity, and skeletal muscle relaxation. Benzodiazepines tends to exert their effects via reinforcement of the gamma-aminobutyric acid-benzodiazepine receptor complex (PDR, 2021_b).

Billing should be educated to avoid use of alprazolam if she is breastfeeding since it can pass through milk. Besides, she should be educated about dosage schedules and warned against abrupt discontinuation since it can lead to withdrawal symptoms. Besides, she should be warned of exceeding the prescribed dosage since the drug can lead to dependence (PDR, 2021_b).  She should be warned not to take alprazolam together with an opiate antagonist since in can increase the risk of respiratory depression, profound sedation, hypotension, and death (PDR, 2021_b). In conclusion, Billing should be referred for cognitive behavioral therapy since it is one of the mainstay therapies for management of obsessive-compulsive disorder (Brock & Hany, 2020).