From the Guidelines
For a patient experiencing a panic attack with normal vital signs, benzodiazepines are the first-line medication treatment, with lorazepam 0.5-2 mg orally or sublingual, diazepam 5-10 mg orally, or alprazolam 0.25-0.5 mg orally being suitable options for rapid symptom relief. These medications work by enhancing the effect of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter that reduces neuronal excitability in the brain, thereby decreasing anxiety and inducing a calming effect 1. For patients with contraindications to benzodiazepines, hydroxyzine 25-50 mg orally can be considered as an alternative. Non-pharmacological interventions should also be implemented, including:
- Placing the patient in a quiet environment
- Using controlled breathing techniques (inhale for 4 seconds, hold for 2, exhale for 6)
- Employing grounding exercises Reassurance and education about the self-limiting nature of panic attacks are essential components of care. For recurrent panic attacks, consider referral for cognitive behavioral therapy and possibly an SSRI antidepressant like sertraline 50-200 mg daily for long-term management, as supported by recent guidelines on managing anxiety and depression 1. It's also important to assess for underlying psychiatric disorders and medical causes of anxiety, as outlined in the distress management guidelines 1.
From the FDA Drug Label
For anxiety, most patients require an initial dose of 2 mg/day to 3 mg/day given twice daily or three times daily. The patient can be ordered lorazepam (PO) for anxiety, with a typical initial dose of 2 mg/day to 3 mg/day given twice daily or three times daily 2.
- The dosage may vary depending on the patient's response and individual needs.
- It is essential to monitor the patient's condition and adjust the dosage as needed and tolerated.
From the Research
Treatment Options for Panic Attack
The patient is experiencing a panic attack with a history of anxiety and panic attacks, but has normal vitals. Considering the patient's condition, the following treatment options can be considered:
- Benzodiazepines: Studies have shown that benzodiazepines such as alprazolam, lorazepam, and clonazepam are effective in treating panic disorder 3, 4. Clonazepam has been considered a first-line agent for panic disorder due to its advantages over other benzodiazepines 3.
- Antidepressants: Antidepressants, particularly SSRIs, have been demonstrated to be effective in preventing panic attacks and improving anticipatory anxiety and avoidance behavior 5. They are also effective in treating coexisting depressive symptomatology.
- Beta-blockers: Beta-blockers such as propranolol may be effective in treating anxiety disorders accompanied by physical symptoms, especially cardiovascular complaints, but their use in panic disorder is not widely researched and should be used cautiously 6.
Medication Considerations
When considering medication for the patient, the following should be taken into account:
- Efficacy: The medication should be effective in treating panic disorder and anxiety symptoms.
- Side effects: The medication should have minimal side effects and be well-tolerated by the patient.
- Dependence and withdrawal: The risk of dependence and withdrawal symptoms should be considered, especially with benzodiazepines 3, 5.
- Comorbid conditions: The presence of comorbid conditions such as depressive illness should be considered when selecting a medication 6, 5.
Non-Pharmacological Treatments
Non-pharmacological treatments such as cognitive-behavioral therapy (CBT) can also be effective in treating panic disorder and should be considered as an option 5, 7. CBT has been shown to have a low relapse rate and can be used in conjunction with medication for optimal results 7.