What is the recommended treatment for a 77-year-old male with panic attacks and anxiety that is relieved by clonazepam (Benzodiazepine)?

From the Guidelines

For a 77-year-old male with panic attacks and anxiety that is relieved by clonazepam, the recommended treatment approach is to transition him to a safer alternative, such as an SSRI, while minimizing benzodiazepine use due to its high-risk profile in older adults. This recommendation is based on the recent study published in the Mayo Clinic Proceedings in 2021 1, which emphasizes the importance of devising a practical approach to discontinuation of benzodiazepines in older patients.

The study suggests considering safer alternatives, including psychological or pharmacological treatments, such as antidepressants, cognitive-behavioral therapy, and integrative strategies 1. Given the patient's age and the risks associated with long-term benzodiazepine use, such as falls, cognitive impairment, and paradoxical reactions, it is crucial to prioritize alternatives.

Some key points to consider in the treatment plan include:

• Starting with a low-dose SSRI, such as sertraline (25mg daily) or escitalopram (5mg daily), and gradually increasing the dose as needed and tolerated
• Combining medication with cognitive behavioral therapy (CBT) to address the patient's panic attacks and anxiety
• Implementing a clear tapering schedule for clonazepam to minimize the risk of rebound or withdrawal symptoms
• Regular follow-up appointments every 2-4 weeks to monitor for side effects and treatment response

It is also important to note that the EMPOWER trial, mentioned in the study 1, demonstrated success in tapering benzodiazepines in older adults through education and a gradual reduction schedule, which can be applied to this patient's treatment plan. A gradual withdrawal strategy, extending over a period of greater than 1 month, is recommended to minimize potential discontinuation effects.

From the FDA Drug Label

Geriatric Patients: There is no clinical trial experience with clonazepam in panic disorder patients 65 years of age and older. In general, elderly patients should be started on low doses of clonazepam and observed closely (see PRECAUTIONS: GERIATRIC USE). Adults: The initial dose for adults with panic disorder is 0. 25 mg bid. An increase to the target dose for most patients of 1 mg/day may be made after 3 days.

The recommended treatment for a 77-year-old male with panic attacks and anxiety that is relieved by clonazepam is to start with a low dose of clonazepam and observe closely. The initial dose can be 0.25 mg bid, with a possible increase to 1 mg/day after 3 days, as this is the target dose for most patients. However, due to the lack of clinical trial experience in patients 65 years of age and older, caution should be exercised, and the patient should be closely monitored 2.

From the Research

Treatment Options for Panic Disorder

The recommended treatment for a 77-year-old male with panic attacks and anxiety that is relieved by clonazepam (a benzodiazepine) can be considered based on the following points:

• Clonazepam has been shown to be effective in treating panic disorder, with studies indicating its efficacy in reducing panic symptoms and frequency of panic attacks 3, 4.
• Benzodiazepines, including clonazepam, have a rapid onset of action and can be effective in the short-term treatment of panic disorder 5, 6.
• However, benzodiazepines can cause tolerance and dependence, and their long-term use should be carefully considered 5.
• Selective serotonin reuptake inhibitors (SSRIs) are also effective in treating panic disorder, but may have a delayed onset of action and can exacerbate anxiety and panic early in the treatment course 5, 6.
• A network meta-analysis found that escitalopram, venlafaxine, and benzodiazepines had greater efficacy and acceptability than placebo for the treatment of panic disorder 7.

Considerations for Treatment

When considering treatment options for this patient, the following points should be taken into account:

• The patient's age and potential comorbidities should be considered when selecting a treatment, as older adults may be more susceptible to the adverse effects of benzodiazepines 3, 6.
• The patient's response to clonazepam and any potential side effects should be carefully monitored, as benzodiazepines can cause cognitive impairment, memory problems, and other adverse effects 6.
• Alternative treatment options, such as SSRIs or other antidepressants, may be considered if the patient experiences adverse effects or if clonazepam is not effective in the long term 5, 7.
• A comprehensive treatment plan should include regular follow-up and monitoring to ensure the patient's safety and efficacy of treatment 3, 7.

Key Findings

Key findings from the studies include:

• Clonazepam is effective in reducing panic symptoms and frequency of panic attacks 3, 4.
• Benzodiazepines have a rapid onset of action and can be effective in the short-term treatment of panic disorder 5, 6.
• SSRIs are also effective in treating panic disorder, but may have a delayed onset of action and can exacerbate anxiety and panic early in the treatment course 5, 6.
• Escitalopram, venlafaxine, and benzodiazepines had greater efficacy and acceptability than placebo for the treatment of panic disorder 7.