What is the best medication to add to a 37-year-old female (YOF) with panic attacks, already on sertraline (Selective Serotonin Reuptake Inhibitor) 100mg/day and Ativan (Lorazepam) PRN (as needed)?

From the Guidelines

For a 37-year-old female with panic attacks who is already on sertraline 100mg/day and as-needed lorazepam, the best medication to add would be buspirone (BuSpar), starting at 5-7.5mg twice daily and gradually increasing to 15-30mg daily in divided doses. Buspirone is a non-benzodiazepine anxiolytic that works by affecting serotonin and dopamine receptors, making it complementary to sertraline's mechanism 1. Unlike benzodiazepines like lorazepam, buspirone is non-addictive and doesn't cause sedation or cognitive impairment, allowing it to be used long-term. It typically takes 2-4 weeks to reach full effectiveness. Some key points to consider when adding buspirone include:

• Monitoring for potential interactions with other serotonergic drugs, as combining these can increase the risk of serotonin syndrome 1
• Starting with a low dose and gradually increasing to minimize side effects
• Being aware of the potential for buspirone to take several weeks to become fully effective Alternatively, if the patient has significant breakthrough anxiety despite sertraline, increasing the sertraline dose to 150-200mg daily could be considered before adding another medication 1. Cognitive behavioral therapy should also be recommended alongside medication management, as the combination of medication and therapy shows better outcomes for panic disorder than either approach alone. Regular follow-up appointments every 2-4 weeks initially would be important to monitor response and adjust dosing as needed.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Panic Disorder

The patient is already on sertraline 100mg/day and Ativan (Lorazepam) PRN, and the goal is to determine the best medication to add to their treatment regimen.

• The current treatment with sertraline is within the recommended range of 50 to 175 mg per day, as shown to be effective in the treatment of panic disorder 2.
• Adding another medication should be considered based on the patient's response to sertraline and the presence of any side effects.
• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are standard treatments for panic disorder, and combining drug treatment with cognitive behavior therapy is the most successful treatment strategy 3.
• Benzodiazepines, such as alprazolam, may be used for short-term treatment, but their use is limited due to the risk of dependence and tolerance 3, 4, 5.

Considerations for Adding a New Medication

When considering adding a new medication to the patient's treatment regimen, the following factors should be taken into account:

• The patient's response to sertraline and any side effects they may be experiencing.
• The potential benefits and risks of adding a new medication, including the risk of interactions with sertraline and Ativan.
• The patient's medical history and any comorbid conditions they may have.
• The potential for the new medication to exacerbate anxiety or panic symptoms, as seen with SSRIs early in treatment 4.

Potential Medication Options

Based on the available evidence, potential medication options to add to the patient's treatment regimen could include:

• Another SSRI, such as paroxetine, which has been shown to be effective in the treatment of panic disorder and has a similar efficacy profile to sertraline 6.
• An SNRI, such as venlafaxine, which has been shown to be effective in the treatment of panic disorder and may have a different side effect profile than SSRIs.
• A benzodiazepine, such as alprazolam, for short-term use, but this should be carefully considered due to the risk of dependence and tolerance 3, 4, 5.