Continuing Education Activity

Buspirone is an anxiolytic. Originally the drug was being developed as an antipsychotic but found not to be effective for psychosis, but it had anxiolytic features that were useful. Buspirone has recently come back into favor, mostly due to its decreased side-effect profile compared to other anxiolytic treatments. Buspirone is primarily used in the treatment of generalized anxiety disorder (GAD). This activity reviews the mechanism of action, adverse event profile, toxicity, dosing, pharmacodynamics, and monitoring of buspirone, pertinent for members of the interprofessional team for the treatment of patients with indications where buspirone is indicated.

Objectives:

• Describe the mechanism of action of buspirone.
• Outline the indications for initiating buspirone.
• Summarize the contraindications and risks associated with initiating buspirone.
• Review interprofessional team strategies for improving care coordination and communication to advance the use of buspirone and improve outcomes in disorders where indicated.

Indications

Buspirone is an anxiolytic first synthesized in 1968 and patented in 1975. Initially, the drug was being developed as an antipsychotic but found not to be effective for psychosis, but it had anxiolytic features that were useful.  Buspirone has recently come back into favor.[1] This return to favor is mostly due to its decreased side-effect profile compared to other anxiolytic treatments. Buspirone's use is primarily for the treatment of generalized anxiety disorder (GAD). Typically, it is used as a second-line agent behind selective serotonin reuptake inhibitors (SSRIs) when a patient does not respond to or cannot tolerate the side effects of SSRIs. Buspirone has also been used as an augmentation agent to reduce SSRIs sexual side effects in particular. Unlike benzodiazepines and barbiturates, there is no associated risk of physical dependence or withdrawal with buspirone use due to the lack of effects on GABA receptors. However, buspirone has little efficacy as an acute anxiolytic as clinical effect typically takes 2 to 4 weeks to achieve.[1] Buspirone is FDA approved for the short and long-term treatment of GAD, as well as short-term symptomatic relief of anxiety. It is as effective as benzodiazepine treatment for GAD.

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed evidence suggesting that buspirone could be effective as augmentation, alongside SSRIs, for unipolar depression. Further studies have also found some utility in subduing the sexual side effects of SSRIs, as well as use as a single agent for the treatment of depression. Although the FDA does not approve these uses, some evidence has suggested the buspirone combined with melatonin has the potential to treat MDD and promote neurogenesis.[2]

It is essential to recognize that buspirone has no use in the treatment of the symptoms of withdrawal from benzodiazepines, barbiturates, or alcohol. Again, this relates to the lack of GABA receptor activity. Furthermore, the effects of buspirone have been shown to diminish in patients who have had previous treatment with benzodiazepines.

Mechanism of Action

Buspirone has a strong affinity for serotonin 5HT1a receptors, where it acts as a partial agonist, which is what some researchers believe produces the majority of clinical effects.[1] It also has a weak affinity for serotonin 5HT2 receptors and acts as a weak antagonist on dopamine D2 autoreceptors. There is no effect on benzodiazepine GABA receptors. How the partial 5HT1a agonism translates into clinical results remains largely unknown; however, some suspect it results from increased serotonergic activity in the amygdala and other parts of the brain’s anxiety/fear circuitry. Due to the delayed anxiolytic effects seen clinically, buspirone likely provides relief through adaptations in 5HT1a receptors.

Administration

Buspirone is available in 5 mg, 7.5 mg, 10 mg, 15 mg, and 30 mg oral tablets. The initial recommended dose for GAD treatment is 15 mg per day, given as either 7.5 mg twice per day, or 5 mg three times per day. Every 2 to 3 days, the dosage may be increased by 5 mg until reaching the desired clinical response. The maximum daily dosage is 60 mg per day. In clinical trials, a typical range of therapeutic effect was between 20 to 30 mg per day of divided doses.

Buspirone has seen occasional off-label use for pediatric anxiety disorders. The dosage has not been well established. In a pilot study of children aged 6 to 14 years, they were started on a daily dose of 5 mg and increased by 5 mg every week up to a maximum daily dose of 20 mg. Another more extensive study with patients aged 6 to 17 years had a higher maximum daily dose of 60 mg.

Food intake decreases absorption; however, concomitant food intake also decreases the amount of the first-pass metabolism of the drug. The net result of taking food with the medication is an increase in the bioavailability. Because of this, patients should understand that they must be consistent in whether they take food along with their medication.

Buspirone gets metabolized by cytochrome P450, CYP3A4, so any potential interactions should undergo an assessment before an initial prescription. The measured bioavailability (using the steady-state area under the curve), increased 14-fold in patients with hepatic impairment and 4-fold in patients with renal impairment.

Adverse Effects

A common side effect is dizziness, which occurs in over 10% of patients.

The following reports of adverse events occurred in 1% to 10% of patients:

• Central nervous system (CNS): Abnormal dreams, ataxia, confusion, dizziness, drowsiness, excitement, headache, nervousness, numbness, outbursts of anger, paresthesia 
• Ophthalmic: Blurred vision 
• Otic: Tinnitus
• Cardiovascular: Chest pain
• Respiratory: Nasal congestion
• Dermatologic: Diaphoresis, skin rash
• Gastrointestinal: Diarrhea, nausea, sore throat
• Neuromuscular and skeletal: Musculoskeletal pain, tremor, weakness

Many of these effects are relieved with the continuation of therapy and with a slow, gradual increase when finding an optimal therapeutic dose. Of note, buspirone has minimal sexual side effects. It has even been shown to help relieve the adverse sexual effects of SSRIs when given as an augmenting agent.

Patients should receive a warning about the possibility of CNS depression. While rarer, patients should also be informed of the potential for akathisia (likely due to central dopamine antagonism) and serotonin syndrome.

Contraindications

• Any history of hypersensitivity reaction with buspirone in the past
• Use of monoamine oxidase inhibitors (MAOI) within 14 days before or after buspirone therapy should be avoided due to the risk of developing serotonin syndrome and/or elevated blood pressure 
• Avoid starting buspirone in patients receiving reversible MAOIs such as linezolid or IV methylene blue due to risk of serotonin syndrome

Monitoring

Offer frequent follow-up after initiating treatment to assess for therapeutic and adverse effects. Encourage patients to stay consistent with their medication schedule and whether they take it with food. As mentioned before, a therapeutic effect typically takes 2 to 4 weeks to take effect. Often, many of the adverse effects will lessen over time, as well. However, the patient should have close monitoring for signs and symptoms of anaphylaxis, akathisia, and serotonin syndrome.

Being a substrate of CYP3A4, buspirone should have continuous checking for interactions that can alter its plasma concentration; this includes grapefruit juice, which can increase its concentration.

Alcohol use can worsen any CNS sedation, and its use requires strict monitoring as well.

Toxicity

Relative to other anxiolytics, buspirone has low toxicity and potential for abuse. There have been no deaths reported from a buspirone overdose alone. In pharmacological trials, healthy male patients were given up to 375 mg per day and developed nausea, vomiting, dizziness, drowsiness, miosis, and gastric distress. While buspirone overdose typically resolves with complete recovery, high suspicion of additional medication overdose should be maintained and investigated.[3][4][5]

Buspirone is a Category B risk in pregnancy, and it is unknown whether it is present in breast milk. One case report stated that buspirone did not transmit via lactation, but the manufacturer does not recommend breastfeeding while taking the medication.

Enhancing Healthcare Team Outcomes

When considering the implementation of buspirone therapy, it is critical to recognize its strengths and weaknesses mentioned above. If a patient is an appropriate candidate, verify that they are invested in the treatment and have an understanding of the possible risks and benefits. The pharmacist must educate the patient on the safe use of the drug. First, the drug should be stored away from the reach of children. Secondly, the patient should only use buspirone for short periods as there are reports of addiction. Third, the patient must understand that they should not drive or use heavy machinery while on this medication. Fourth, the patient should not combine buspirone with other sedatives or alcohol. Patients who continue to get refills should be encouraged to seek counseling from a healthcare professional. Encourage individuals to be patient at the initiation of therapy and follow up within a month to assess effectiveness.[6][7]

Finally, the pharmacist must communicate with the physician if there is evidence of drug misuse. In an era where drug abuse continues to result in high mortality, the onus is on all healthcare workers to ensure that patients only use buspirone for legitimate purposes. Nursing can monitor for adverse effects, including drug-drug interactions, which can be verified with the pharmacist and reported to the prescriber. Nursing can also provide patient counseling to reinforce the pharmacists' counsel. Any mental health personnel on the case need inclusion on any patient findings, and they should also have the ability to share their findings with the healthcare team. Only with this type of interprofessional cooperation can buspirone have optimal therapeutic results with minimal adverse effects. [Level V]