Appropriate use of PRNs

For our purposes, PRNs are

• propranolol for social anxiety

• hydroxyzine for anxiety

• sleep meds

These medications provide symptomatic relief but not treat the (anxiety) disorder itself

Appropriate use of PRNs

At the beginning of treatment, until SSRI/SNRI kicks in

Especially if patient is not able to function = severe insomnia, debilitating anxiety

After the first couple weeks/months of treatment, should NOT be needed

Ongoing use should not exceed 2-3x/wk, for very specific situations eg. giving presentations - propranolol

If ongoing use exceed 2-3x a week, standing med needs to be increased since at this point they need the PRN “more days than not”. One medication is better than 2 (3, 4)

If you increase dose -> prepare them that they will need less PRNs. Refrain from automatically refilling PRNs indefinitely - see RN escalation criteria

Patient doing well on a regimen and not willing to change

Patient on 2+ standing meds already (dose maxed out or dose is highest that the pt agreed to)

Inappropriate use of PRNs

Long term, instead of an SSRI/SNRI

Instead of patient being on one medication, they remain on 3-4

Please note ongoing need for refill of propranolol, hydroxyzine, sleep meds is an RN→ Provider Escalation Criteria

If you are titrating the primary medication appropriately, PRNs should not be needed months into the treatment

Some anxious patients “just want PRNs” and are super hesitant about getting on an SSRI/SNRI; Points to make if patient wants only PRNs instead of standing meds

• “As needed” medications usually provide a temporary relief instead of targeting the root cause of the problem.

• You frequently need multiple “as needed” medications to address different symptoms of the same issues (eg. insomnia and daytime anxiety that are both just symptoms of the same anxiety disorder), as opposed to one daily medication that would address all of them.

• It can be easier to stay on track with a medication you take once a day,, since you do not have to remember to take something multiple times a day. Taking the medications consistently is key to helping them be most effective.

• “As needed” medications will only help you in the moment, so you will still have to experience anxiety and the “ebbs and flows” of symptoms and medication effect. It will help you for a couple hours after you take it. but then anxiety may return). Whereas once you take a daily medication routinely, your symptoms may completely go away so you do not have to deal with them anymore.

• If you want to just use “as needed” medications, let’s monitor how frequently you use them. My cutoff is usually 3 times a week. If you need it more frequently, that could indicate that you have anxiety more days than not and we could consider a daily medication.

• Let’s also keep an eye on how many different “as needed” medications we are using because you can end up with more medication burden on your body than just taking a daily reuptake inhibitor, such as an SSRI.