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 due to their efficacy, safety profile, and long-term effectiveness. 1, 2

First-Line Pharmacological Options

SSRIs

• Sertraline:

  • Starting dose: 25-50 mg daily
  • Target dose: 50-200 mg daily
  • Demonstrated efficacy in multiple clinical trials with significant reduction in panic attack frequency 3, 4
  • FDA-approved for panic disorder 5

• Fluoxetine:

  • Starting dose: 10 mg daily
  • Target dose: 20-60 mg daily
  • Dose should be increased to 20 mg after one week 6

• Paroxetine:

  • Starting dose: 20 mg daily
  • Target dose: 20-50 mg daily 7
  • Effective for panic disorder but has higher rates of sexual dysfunction and discontinuation syndrome compared to other SSRIs 1, 7

SNRIs

• Venlafaxine:
  • Recommended as an alternative first-line option 1
  • Effective for anxiety disorders with a "weak" recommendation but "low" certainty of evidence 1

Administration Guidelines

1. Initiation: Start at lower doses than those used for depression (e.g., sertraline 25 mg, fluoxetine 10 mg) to minimize initial anxiety/activation 1, 6
2. Titration: Increase dose gradually every 1-2 weeks as tolerated 1
3. Duration: Treatment should continue for at least 12 weeks to properly evaluate efficacy 7
4. Maintenance: Long-term treatment (9-12 months minimum) is often necessary after symptom remission 2

Second-Line Options

Benzodiazepines

• May be used for short-term treatment or in non-responsive cases 2
• Should be avoided in patients with history of substance abuse/dependence 2
• Examples: alprazolam, clonazepam
• Caution: Risk of dependence, tolerance, and withdrawal symptoms 8

Tricyclic Antidepressants

• As effective as SSRIs but with poorer tolerability 2, 9
• Examples: imipramine, clomipramine
• Limitations: Anticholinergic side effects, cardiotoxicity in overdose, delayed onset of action (4-6 weeks) 8

Non-Pharmacological Treatment

Cognitive Behavioral Therapy (CBT) is highly effective for panic disorder:

• As effective as medication for panic disorder 9
• Can be used alone or in combination with medication 9
• Particularly beneficial for long-term outcomes 2

Treatment Algorithm

1. Initial Treatment:

   • Start with an SSRI (sertraline, fluoxetine, or paroxetine) at a low dose
   • AND/OR refer for CBT if available

2. After 4-6 weeks:

   • If partial response: Increase SSRI dose within recommended range
   • If no response: Switch to a different SSRI or an SNRI

3. After 12 weeks:

   • If good response: Continue treatment for at least 9-12 months
   • If inadequate response: Consider adding CBT (if not already initiated) or switching medication class

4. Treatment-Resistant Cases:

   • Consider combination therapy (medication + CBT)
   • Consider trial of a TCA or benzodiazepine (short-term)

Important Considerations

• Monitoring: Watch for increased anxiety, agitation, or suicidal ideation, especially during the first few weeks of treatment 1
• Discontinuation: Taper medications gradually (over weeks to months) to avoid withdrawal symptoms, particularly with paroxetine and SNRIs 1, 7
• Comorbidities: Panic disorder frequently co-occurs with depression, other anxiety disorders, and substance use disorders 3
• Drug Interactions: Be aware of potential interactions, especially with SSRIs that affect CYP450 enzymes 1

Special Populations

• Pregnancy/Lactation: Requires careful risk-benefit assessment
• Elderly: Use lower starting doses and titrate more slowly 1
• Hepatic/Renal Impairment: Dose adjustments may be necessary, particularly for fluoxetine and paroxetine 6

By following this evidence-based approach to medication selection and management, most patients with panic disorder can achieve significant symptom reduction and improved quality of life.