What non-controlled substance medications can be used as needed for panic attacks?

Non-Controlled Substances for As-Needed Treatment of Panic Attacks

Hydroxyzine (Vistaril, Atarax) is the most effective non-controlled medication for as-needed treatment of panic attacks, with dosages of 25-50mg taken as needed for acute anxiety symptoms. 1, 2

First-Line Non-Controlled Options

Hydroxyzine

• Dosage: 25-50mg orally as needed
• Mechanism: Antihistamine with sedative properties
• Evidence: Shown to be effective for acute anxiety symptoms 3, 4
• Onset: 15-30 minutes
• Duration: 4-6 hours
• Advantages:
  • Not habit-forming
  • Not a controlled substance
  • Effective for both anxiety and associated nausea
  • Can be used safely on an as-needed basis

Propranolol

• Dosage: 10-40mg orally as needed
• Mechanism: Beta-blocker that reduces physical symptoms of anxiety (tremor, tachycardia)
• Evidence: Effective for performance anxiety and physical symptoms of panic 5
• Onset: 30-60 minutes
• Duration: 3-6 hours
• Best for: Patients whose panic attacks are predominantly characterized by physical symptoms like racing heart, trembling, and sweating

Second-Line Non-Controlled Options

Diphenhydramine (Benadryl)

• Dosage: 25-50mg orally as needed
• Mechanism: Antihistamine with sedative effects
• Evidence: Used for chemical restraint in acute agitation 1
• Caution: More sedating than hydroxyzine, can cause significant drowsiness

Buspirone

• Dosage: 5-10mg orally
• Mechanism: Serotonin 1A receptor partial agonist
• Limitation: Takes 2-4 weeks for full effect, less suitable for as-needed use
• Note: Better for ongoing treatment than acute management

Algorithm for Selection

1. For predominantly physical symptoms (racing heart, trembling):

   • Start with propranolol 10-20mg as needed
   • Can increase to 40mg if needed and tolerated

2. For predominantly psychological symptoms (fear, dread):

   • Start with hydroxyzine 25mg as needed
   • Can increase to 50mg if needed and tolerated

3. For mixed symptoms with significant nausea:

   • Hydroxyzine 25-50mg (has antiemetic properties)

Important Considerations

Monitoring and Precautions

• Hydroxyzine:

  • Monitor for excessive sedation
  • Use caution in elderly patients (start at lower dose of 10-25mg)
  • Contraindicated in patients with prolonged QT interval 2
  • Avoid combining with other CNS depressants

• Propranolol:

  • Contraindicated in asthma, COPD, heart block, bradycardia
  • Monitor blood pressure and heart rate
  • Use caution in diabetics (can mask hypoglycemia symptoms)

Common Pitfalls to Avoid

1. Undertreatment: Starting with too low a dose of hydroxyzine (less than 25mg) may be ineffective for acute panic

2. Overreliance: Even non-controlled medications should not be used too frequently (more than twice weekly) to prevent tolerance

3. Ignoring underlying causes: As-needed medications should be part of a comprehensive treatment plan that addresses the root causes of panic attacks

4. Medication interactions: Hydroxyzine can have additive effects with other sedating medications 2

5. Delayed treatment: Having the medication readily available is crucial, as panic attacks often occur suddenly

When to Consider Other Options

• If symptoms are not controlled with these non-controlled options
• If panic attacks occur more than twice weekly (consider daily preventive medication)
• If significant comorbid depression is present (consider SSRI/SNRI)

Remember that while these medications can help manage acute symptoms, they don't address the underlying causes of panic disorder. For optimal outcomes, combine as-needed medication with cognitive-behavioral therapy and lifestyle modifications.