What medications are recommended for treating panic disorder?

Medications for Panic Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for panic disorder, with sertraline and fluoxetine being FDA-approved options with strong evidence of efficacy. 1, 2, 3

First-Line Medications

SSRIs

• Sertraline (Zoloft)

  • Starting dose: 25-50 mg daily
  • Target dose: Up to 200 mg daily
  • FDA-approved for panic disorder 3
  • Demonstrated efficacy in multiple clinical trials 4, 5
  • Common side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction

• Fluoxetine (Prozac)

  • Starting dose: 10 mg daily
  • After 1 week, increase to 20 mg daily
  • Maximum dose: Up to 60 mg daily (higher doses not systematically evaluated)
  • FDA-approved for panic disorder 2
  • Common side effects: Anxiety, insomnia, nervousness, gastrointestinal effects, sexual dysfunction

Dosing Considerations

• Start with lower doses in panic disorder patients compared to depression treatment
• For fluoxetine, begin with 10 mg daily for 1 week, then increase to 20 mg 2
• For sertraline, begin with 25-50 mg daily 1
• Gradual dose titration is essential to minimize initial anxiety/activation

Second-Line Medications

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine

  • Starting dose: 37.5 mg daily
  • Target dose: Up to 225 mg daily
  • Different side effect profile than SSRIs 1

• Duloxetine

  • Starting dose: 30 mg daily
  • Target dose: 60 mg daily 1

Tricyclic Antidepressants

• As effective as modern antidepressants but less well tolerated 6, 7
• Consider when SSRIs/SNRIs are ineffective or contraindicated

Short-Term/Adjunctive Treatment

Benzodiazepines

• Effective for rapid symptom control 6, 8
• Should be used cautiously due to:
  • Risk of tolerance and dependence
  • Not recommended for patients with history of substance abuse
  • Best used short-term while waiting for antidepressants to take effect
• Alprazolam has specific evidence for panic disorder 6

Treatment Duration and Monitoring

• Continue medication for several months beyond initial response
• Maintenance treatment for 12-24 months after achieving remission is recommended 1
• Monitor for:
  • Suicidal ideation (especially in patients under 24 years)
  • Serotonin syndrome when combining serotonergic medications
  • Behavioral activation/agitation (more common early in treatment)
  • Drug interactions (SSRIs inhibit various CYP450 enzymes)

Combination Treatment

• Cognitive Behavioral Therapy (CBT) combined with medication provides the strongest evidence for effective treatment 1, 6, 7
• CBT addresses underlying cognitive patterns and avoidance behaviors
• Consider CBT referral for all patients with panic disorder

Special Populations

• Elderly patients: Use lower doses and titrate more slowly 1, 2
• Hepatic impairment: Lower doses recommended 2, 3
• Pregnancy: Carefully weigh risks/benefits; consider tapering in third trimester 2

Discontinuation

• Gradual tapering is essential to minimize discontinuation symptoms
• Fluoxetine has lower risk of discontinuation syndrome due to long half-life 1
• Paroxetine, fluvoxamine, and sertraline have higher risk of discontinuation syndrome 1

Treatment Algorithm

1. Start with SSRI (sertraline or fluoxetine) at low dose
2. Gradually titrate dose over 4-8 weeks to effective level
3. If partial response, continue titration to maximum tolerated dose
4. If inadequate response after 8-12 weeks at maximum tolerated dose, switch to another SSRI or SNRI
5. For severe, disabling symptoms at initiation, consider short-term benzodiazepine coverage
6. Refer for CBT in conjunction with medication management
7. After symptom remission, continue treatment for 12-24 months before considering gradual taper