What are the first-line medications for treating anxiety?

From the Guidelines

First-line medications for treating anxiety typically include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

Medication Options

• Common SSRIs prescribed include sertraline (starting at 25-50mg daily, increasing to 50-200mg), escitalopram (10-20mg daily), fluoxetine (20-80mg daily), and paroxetine (20-50mg daily) 1.
• SNRIs like venlafaxine (75-225mg daily) and duloxetine (30-120mg daily) are also effective options 1.

Mechanism of Action

These medications work by increasing serotonin and/or norepinephrine levels in the brain, which helps regulate mood and anxiety 1.

Treatment Duration and Combination Therapy

Treatment should continue for at least 6-12 months after symptom improvement to prevent relapse. Medication should ideally be combined with cognitive-behavioral therapy for optimal results 1.

Side Effects and Alternatives

Patients should be aware that these medications typically take 2-4 weeks to show effectiveness, and side effects like nausea, headache, and sexual dysfunction may occur initially but often improve with time. Benzodiazepines like lorazepam or clonazepam may be used short-term for acute anxiety but aren't recommended for long-term use due to dependency risks. The choice of medication for anxiety within the SNRI class may also be governed by other considerations such as pharmacokinetics, pharmacodynamics, tolerability, cost, insurance formularies, and unique risks leading to warnings or precautions 1.

From the FDA Drug Label

Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking Prozac Clinical Worsening and Suicide Risk — Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down.

The first-line medications for treating anxiety are not explicitly stated in the provided drug label. However, fluoxetine (Prozac) is mentioned as an antidepressant that may be used to treat anxiety, but it may also exacerbate anxiety in some patients.

• Key points to consider when prescribing fluoxetine for anxiety include:
  • Monitoring for worsening anxiety or suicidal ideation
  • Caution when co-administering with other CNS active drugs
  • Potential interactions with other medications, such as benzodiazepines and anticonvulsants 2

From the Research

First-Line Medications for Anxiety

The following medications are considered first-line treatments for anxiety:

• Selective serotonin reuptake inhibitors (SSRIs) such as sertraline 3, escitalopram 4, and fluoxetine 5
• Serotonin norepinephrine reuptake inhibitors (SNRIs) such as duloxetine 4 and venlafaxine 6

Efficacy of Medications

Studies have shown that:

• SSRIs and SNRIs are effective in treating anxiety disorders, with similar efficacy between the two classes 6
• Higher doses of SSRIs are associated with greater symptom improvement, but also increased side effects 6
• Duloxetine and escitalopram have shown better efficacy in treating generalized anxiety disorder 4
• Vortioxetine has shown better acceptability and tolerability, but worse efficacy and response rate compared to other medications 4

Considerations for Treatment

When selecting a medication for anxiety, clinicians should consider:

• Age and co-morbidity of the patient 7
• Prior treatment and response to medication 7
• Potential side effects and tolerability of the medication 5
• The use of psychotherapy in conjunction with medication, particularly in pediatric patients 7