From the Guidelines
For a 19-year-old patient with anxiety and panic attacks who developed a drug rash to sertraline, I recommend switching to an alternative SSRI such as fluoxetine (Prozac) starting at 10mg daily and gradually increasing to 20mg daily after one week if tolerated, as supported by the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1.
Alternative Treatment Options
Other options include escitalopram (Lexapro) starting at 5mg daily and increasing to 10mg daily after one week. If SSRIs are contraindicated due to cross-sensitivity concerns, consider a medication from a different class such as venlafaxine (Effexor XR) starting at 37.5mg daily and gradually titrating upward, or buspirone starting at 5mg twice daily and increasing to 10mg twice daily, as suggested by the guideline for the assessment and treatment of children and adolescents with anxiety disorders 1.
Importance of Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy (CBT) should be initiated concurrently as it's highly effective for anxiety and panic disorders without medication side effects, as noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1.
Monitoring and Non-Pharmacological Approaches
The patient should be monitored closely for any signs of allergic reaction to the new medication during the first few weeks of treatment. Non-pharmacological approaches including regular exercise, mindfulness practices, and avoiding caffeine and alcohol can also help manage symptoms during this medication transition.
Rationale for Recommendation
The recommendation to try another SSRI is based on the fact that allergic reactions to one SSRI don't necessarily indicate class-wide sensitivity, though caution is warranted, as indicated by the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1.
From the Research
Treatment Options for Anxiety and Panic Attacks
- For a 19-year-old patient with anxiety and panic attacks, selective serotonin reuptake inhibitors (SSRIs) are considered a standard first-line pharmacologic treatment 2.
- However, since the patient recently developed a drug rash to sertraline, alternative treatments should be considered.
Alternative Treatments
- Other antidepressants such as serotonin-norepinephrine reuptake inhibitors, serotonin multimodal agents, tricyclic antidepressants, monoamine oxidase inhibitors, and mirtazapine can be considered as alternatives to SSRIs 2.
- Benzodiazepines can also be considered as a first-line pharmacologic treatment for panic disorder 2.
- Cognitive-behavioral therapy (CBT) is also a strongly supported treatment for panic disorder 2.
Considerations for Patients with Skin Rashes
- A case report suggests that some individuals may be sensitive to increases in serotonin concentrations, which can cause dermal side reactions to SSRI-drugs 3.
- Another study found that chronic idiopathic urticaria associated with panic disorder responded favorably to selective serotonin reuptake inhibitor antidepressants, suggesting a common pathogenic factor involving serotoninergic mechanisms 4.
Choosing an Alternative SSRI
- A meta-analysis found that citalopram, sertraline, paroxetine, fluoxetine, and venlafaxine were significantly superior to placebo for panic symptoms, with varying degrees of effectiveness 5.
- The same meta-analysis found that paroxetine, fluoxetine, fluvoxamine, citalopram, venlafaxine, and mirtazapine were effective for overall anxiety symptoms 5.