Benzodiazepines for Acute Panic Attacks
For acute panic attacks, alprazolam (Xanax) is the most appropriate as-needed medication, typically starting at 0.25-0.5 mg orally as needed, with a maximum of 4 mg in 24 hours. 1
First-Line Medication Options
Alprazolam (Xanax)
- Dosing: 0.25-0.5 mg orally as needed for acute panic attacks
- Onset: Rapid onset of action (peak levels in 0.7-2.1 hours) 2
- Duration: Half-life of 12-15 hours provides adequate coverage 2
- Maximum daily dose: 4 mg/day (higher doses increase risk of dependence) 1
- Advantages: Specifically effective for panic disorder, rapid onset of action
Lorazepam (Ativan)
- Dosing: 0.5-1 mg orally as needed (maximum 4 mg in 24 hours) 3
- Reduced dosing: 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours) 3
- Route options: Oral tablets can be used sublingually for faster onset
- Alternative administration: If unable to swallow, midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 3
Clinical Considerations
Patient Selection
- Best for patients with:
- Infrequent panic attacks requiring rapid relief
- No history of substance abuse
- No contraindications (severe pulmonary insufficiency, severe liver disease, myasthenia gravis) 3
Important Precautions
- Dependence risk: Limit prescriptions to shortest effective duration
- Tolerance: May develop with regular use
- Withdrawal: Can occur with abrupt discontinuation, potentially severe with higher doses 1
- Cognitive effects: May cause memory impairment, confusion, or drowsiness 1
- Paradoxical reactions: Rarely may cause increased anxiety or agitation 4
Monitoring
- Start with lowest effective dose
- Monitor for sedation, cognitive impairment, and signs of dependence
- Assess effectiveness against target symptoms
- Avoid concurrent use with other CNS depressants including alcohol 1
Alternative Approaches
Non-Benzodiazepine Options
- SSRIs: More appropriate for long-term management rather than as-needed treatment 5
- Cognitive-behavioral therapy: More effective long-term solution but not suitable for acute attacks 5
Extended-Release Formulations
- Alprazolam-XR: Consider for patients who need more consistent coverage with less "clock-watching" 6
- Provides sustained therapeutic concentrations for 24 hours with once-daily dosing
- Lower abuse potential and reduced incidence of sedation compared to immediate-release formulation
Patient Education
- Instruct patients not to drive or operate machinery until they know how the medication affects them
- Advise against alcohol consumption during treatment
- Explain that medication should be used only as needed for acute attacks
- Warn against abrupt discontinuation after regular use
- Emphasize the importance of using the lowest effective dose for the shortest duration
Benzodiazepines remain the most effective as-needed medication for acute panic attacks when used appropriately, with alprazolam being particularly well-studied for this indication.