Are there medications other than Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) that treat panic disorder?

Medications for Panic Disorder Beyond SNRIs

SSRIs are the first-line medication treatment for panic disorder due to their proven efficacy and favorable side effect profile compared to other medication classes. 1

First-Line Treatment Options

SSRIs (Selective Serotonin Reuptake Inhibitors)

• FDA-approved for panic disorder:

  • Sertraline (Zoloft) - FDA-approved specifically for panic disorder with or without agoraphobia 2
  • Fluoxetine (Prozac) - FDA-approved for panic disorder with or without agoraphobia 3
  • Paroxetine (not in evidence but commonly used)

• Efficacy: SSRIs have demonstrated high response rates with a Number Needed to Treat (NNT) of 4.70 4

• Tolerability: Better tolerated than tricyclic antidepressants with fewer dropouts (18% vs 31%) 5

• Administration: Start at low doses (e.g., sertraline 25-50 mg/day) and gradually increase every 1-2 weeks as needed 1

Second-Line Treatment Options

Benzodiazepines

• Can be used as adjunctive treatment at the start of SSRI therapy for acute relief of symptoms 1
• Important limitations:
  • Use should be limited to 2-4 weeks due to risk of dependence and tolerance 1
  • Higher dropout rates compared to SSRIs 6
  • Risk of physical dependence with long-term use

Tricyclic Antidepressants (TCAs)

• Effective for panic disorder with efficacy comparable to SSRIs 5
• Limitations:
  • Less favorable side effect profile than SSRIs 5
  • Higher dropout rates (31% vs 18% for SSRIs) 5
  • Greater risk of toxicity in overdose

Other Medication Options

Other Antidepressants

• Mirtazapine, reboxetine, and nefazodone have shown preliminary efficacy in panic disorder 7
• These may be considered for treatment-resistant cases

Anticonvulsants

• Levetiracetam has shown some promise in preliminary studies 7
• Limited evidence base compared to standard treatments

Treatment Algorithm

1. Start with an SSRI (sertraline or fluoxetine) at a low dose and titrate gradually

   • Begin with sertraline 25-50 mg/day or fluoxetine at low dose
   • Increase dose gradually every 1-2 weeks based on response and tolerability

2. Consider short-term benzodiazepine (e.g., alprazolam) during initial 2-4 weeks of SSRI treatment to manage acute symptoms 1

3. If inadequate response to first SSRI:

   • Optimize dose and ensure adequate trial duration (8-12 weeks)
   • Switch to another SSRI if inadequate response or intolerable side effects

4. For treatment-resistant cases:

   • Consider TCAs despite less favorable side effect profile
   • Evaluate newer options like mirtazapine or other novel agents 7

Treatment Duration and Discontinuation

• Maintain treatment for at least 9-12 months after remission to prevent relapse 1
• Discontinue medication gradually over several weeks to avoid discontinuation syndrome 1
• Monitor closely for symptom recurrence during and after discontinuation

Important Considerations

• Onset of action: SSRIs typically take 2-4 weeks to show therapeutic effect, which may be a limitation compared to benzodiazepines' rapid onset 6
• Combination therapy: Cognitive-behavioral therapy (CBT) combined with medication may be more effective than either treatment alone for resistant cases 1
• Side effect monitoring: Regular assessment for adverse effects, particularly during initiation and dose changes

The Cochrane review provides strong evidence that antidepressants as a class are more effective than placebo for panic disorder, with an NNT of 7, meaning seven people need to be treated for one to benefit 8.