Fabrication Factory

Important items to note in your intro (not all of these items will factor into your decision, but all should be considered when researching the options):

• 46-year-old white male
• Welder at a local steel fabrication factory (high risk profession with heavy and dangerous machinery)
• Mild HTN
• Drinks 3-4 beer/night to ease anxiety
• 15 lbs. overweight
• Patient is single, he is attempting to care for aging parents in his home
• HAM-A Score = 26

Purpose Statetment:

The purpose of this paper is to reduce the patient’s anxiety and improve his quality of life.  My goal in treating this patient is to reduce his HAM-A score from a level of severe anxiety (>/= 26) to a level of mild anxiety (between 8-14).  I intend to achieve this within a period of 6-12 weeks by prescribing an an appropriate pharmacologic agent from the choices presented.

 

Decision Point :1

Preferred option:  Zoloft 50mg

• SSRIs are the first line option for anxiety (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340395/).  This is the key concept for this case!!
• SSRIs are proven effective and have a tolerable side effect profile that fits this patient’s lifestyle.
• SSRIs are safe to use when a patient consumes alcohol*, do not significantly increase blood pressure* (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755252/), and will not make patient dizzy or confused in a way that will affect his ability to weld*.

*As mentioned in the Decision Tree Guide, only discuss or cite side effects specific to your patient

Alternate/ not preferred option:  Impramine

• TCA’s areeffective for anxiety and depression (equal to SSRIs), but have generally been replaced by SSRIs due to tolerability. (https://pubmed.ncbi.nlm.nih.gov/12197851/).
• It is not safe to drink while taking a TCA, especially when the patient first starts treatment.  This is especially important since the patient is a welder (https://www.uofmhealth.org/health-library/d00259a1)
• There may be a connection between weight gain and imipramine.  But, you will find conflicting research and data on this. It seems that some people gain weight and some do not.
• Research right bundle branch block!!

 

Alternate/ not preferred option:  Buspirone

• This medication is approved for GAD and proven effective, but is generally reserved as second line or adjunct therapy to SSRIs.  Buspirone simply does not have the depth of evidence to support using it over an appropriate SSRI.  (Chessick CA, Allen MH, Thase M, Batista Miralha da Cunha AB, Kapczinski FF, de Lima MS, et al. Azapirones for generalized anxiety disorder. Cochrane Database Syst Rev. (2006) 2006:Cd006115. doi: 10.1002/14651858.CD006115)
• Minor item to note, Buspirone is more likely to make a patient dizzy than an SSRI.

 

Decision Point #2:

Preferred option:  Increase to Zoloft 75mg

• Straight forward option. We dose this medication in 25mg increments (refer to Week #4).
• Therapy is working but we did not achieve the goal defined in the purpose statement.

 

Alternate/ not preferred options:  Increase dose to 100mg

• See above, we don’t increase doses by 50mg. (package insert)

 

Alternate/ not preferred options:No dose/ drug change

• While we may see additional benefit from Zoloft 25mg in the coming weeks, the patient is not going to improve from a score of 18 all the way down to below 14 or less.
• Keep in mind, I stated a goal HAMA score of 8-14, but if he scores lower, that is ok too.  If you state a specific goal in your intro, you can use it to justify your choices later on.

 

Decision Point #3:

 

Preferred option:  Maintain current dose

• Simply put, our patient achieved the goal of therapy (which was reasonable and evidence based).
• Patient is not experiencing any intolerable side effects or other reason to change dose/ therapy.

 

Alternate/ not preferred options: Increase to Zoloft 100mg

• Similar to above, patient is at goal, so why increase the dose?  You could argue that there is still room for improvement and that the patient could achieve a HAM-A below 7.
• I think this is reasonable if well justified, but the “best” option is to continue the current dose and allow the patient to cope.
• SSRIs are not intended to be lifelong treatment (they often are, but that is not the goal).  We want to reduce symptoms of anxiety and help the patient learn coping skills with the hope that they will be able to stop the medication.

 

Alternate/ not preferred options Augment with Buspirone:

• We never augment with a second agent until the first agent is optimized.

 

Ethical consideration:

The key consideration in my opinion is non-maleficence.  The patient is already struggling with the stress of work. We cannot afford to prescribe something that could cause an accident at his work and possibly get him fired or someone hurt.  This would be worse than the patient’s current state.

Patient is an adult and takes care of himself, so autonomy and consent do not play a major role here.