The best next drug in the course of generalized anxiety disorders: the “PN-GAD-algorithm”

Abstract

Objective. Today, there are many pharmacotherapeutic options for generalized anxiety disorder (GAD). The question is, which is the best medication for a particular patient at a particular moment? This is especially challenging because GAD is by definition a chronic disorder and new interventions should learn from earlier experiences. An algorithm which can help to use pretreatment information for drug selection is the “Pretreatment – Next Treatment (PN) – Algorithm”. This article introduces an PN-algorithm for GAD. Methods and results. For the development of a GAD-specific PN-algorithm, all possible pharmacological options for GAD are reviewed and brought into a rank order on the basis of scientific evidence regarding efficacy, tolerability, or price: (1) pregabalin, (2) venlafaxine XR, (3) selective serotonin reuptake inhibitors, (4) tricyclic antidepressants, (5) buspirone, (6) antipsychotics, (7) benzodiazepines, and (8) hydroxyzine. Based on this hierarchy and patient-specific information, a decision algorithm is derived, which allows to assess and evaluate pretreatment and to select the drug with no contraindications, limited negative or convincing positive effects, or the option which has not been used so far but which is the next compound in the hierarchy. Conclusions. The “PN-GAD-algorithm” can be easily translated into a checklist to support clinical decision-making. It can also help to increase patient empowerment and cooperation in long-term treatment.

Key Words::

• Generalized anxiety disorder
• drug selection
• treatment algorithm
• PN-algorithm
• shared decision-making

Acknowledgements

None.

Statement of Interest

Linden has served as a consultant and on advisory boards for Pfizer, Janssen, Lilly, Sanofi, Novartis, Servier and is employed at the Federal German Pension Agency. Bandelow has received grant/research support from Servier and has served on advisory boards for Pfizer, Lilly, Lundbeck, Merck, GlaxoSmithKline, and AstraZeneca. Boerner has received honoraria from Pfizer and Janssen and has served on advisory boards for Pfizer. Brasser is an employee of Pfizer. Kasper has received grant/research support from Bristol Myers-Squibb, Eli Lilly, GlaxoSmithKline, Lundbeck, Organon, Sepracor, and Servier and has served as a consultant or on advisory boards for AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Lundbeck, Merck Sharp and Dome (MSD), Novartis, Organon, Pfizer, Schwabe, Sepracor, and Servier and has served on speakers’ bureaus for Angelini, AstraZeneca, Bristol Myers-Squibb, Eli Lilly, Janssen, Lundbeck, Pfizer, Pierre Fabre, Schwabe, Sepracor, and Servier. Möller has received grants and is a consultant for and on the speakership bureaus of AstraZeneca, Bristol-Myers Squibb, Eisai, Eli Lilly, GlaxoSmithKline, Janssen Cilag, Lundbeck, Schwabe, Merck, Novartis, Organon, Pfizer, Sanofi-Aventis, Sepracor, Servier, and Wyeth. Pyrkosch has no conflict of interest to declare. Volz has served as a consultant or on advisory boards for Astra/Zeneca, Eli Lilly, Lundbeck, Pfizer, Schwabe, Janssen, Otsuka, Merz, Wyeth and has serves on speakers’ bureaus for Astra/Zeneca, Eli Lilly, Lundbeck, Schwabe, Janssen, Merz, Wyeth, Lichtwer, Steigerwald, Hormosan, and Bristol-Myers Squibb. Wittchen has received grants/research support and honoraria from Pfizer, Lundbeck, and Servier and has served as a consultant for Pfizer, Lundbeck, and Servier.

Notes

¹ Some of the presented drugs may not (or not yet) have been licensed for the treatment of GAD in every country.