What are the FDA-approved medications for treating panic disorder?

FDA-Approved Medications for Panic Disorder

The FDA-approved medications for treating panic disorder are sertraline, paroxetine, alprazolam, and clonazepam. These medications have demonstrated efficacy in reducing panic attacks and associated symptoms in controlled clinical trials.

First-Line Treatment Options

SSRIs

• Sertraline (Zoloft)

  • FDA-approved for panic disorder 1
  • Starting dose: 25-50 mg daily
  • Target dose: Up to 200 mg daily
  • Common side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction 2

• Paroxetine

  • First SSRI approved for panic disorder 3
  • Dosing typically starts at 10 mg daily with gradual titration
  • Effective in reducing panic attack frequency and improving associated symptoms 3

Benefits of SSRIs for Panic Disorder

• Recommended as first-line treatment due to favorable safety profile 2
• No risk of dependence (unlike benzodiazepines)
• Safer in overdose than tricyclic antidepressants
• Effective for comorbid conditions (depression, other anxiety disorders)

Benzodiazepines

High-Potency Benzodiazepines

• Alprazolam

  • FDA-approved for panic disorder 4
  • Demonstrated superiority to placebo in multiple controlled studies
  • Average effective dose: 5-6 mg/day in clinical trials 4
  • Rapid onset of action

• Clonazepam

  • FDA-approved for panic disorder 5
  • Effective dose range: 0.5-4 mg/day
  • In clinical trials, 62% of patients became free of panic attacks (vs. 37% on placebo) 5
  • Mean effective dose in trials: 2.3 mg/day 5

Considerations with Benzodiazepines

• Rapid onset of action (advantage for acute symptoms)
• Risk of dependence and withdrawal
• Potential for tolerance
• Not recommended for first-line long-term treatment
• Significant risk of respiratory depression when combined with other medications like buprenorphine 2

Treatment Algorithm

1. Start with an SSRI (sertraline or paroxetine)

   • Begin with low doses and titrate gradually
   • Evaluate response after 2-3 weeks initially, then at 4-6 weeks for full effect 2
   • Continue effective treatment for at least 6-12 months

2. For patients with severe symptoms or needing rapid relief:

   • Consider short-term adjunctive benzodiazepine (alprazolam or clonazepam)
   • Plan for gradual tapering once SSRI takes effect
   • Avoid in patients with history of substance use disorders

3. For non-responders to initial SSRI:

   • Switch to the alternative SSRI
   • Consider SNRIs (though not FDA-approved specifically for panic disorder)

Important Clinical Considerations

• Never abruptly discontinue benzodiazepines due to risk of severe withdrawal, including seizures and delirium 2
• Regular monitoring for emergence of depression or suicidal ideation is crucial, especially in younger patients 2
• Gradual tapering is essential when discontinuing any medication for panic disorder
• Relapse risk increases within the first year after stopping medication 2
• Combining medication with cognitive behavioral therapy is considered the most successful treatment strategy 6

Special Populations

• Pregnancy/lactation: SSRIs generally preferred over benzodiazepines
• Elderly patients: Start with lower doses of SSRIs; use benzodiazepines with extreme caution due to fall risk
• Patients with substance use history: Avoid benzodiazepines; rely on SSRIs as primary treatment

While other medications like tricyclic antidepressants may be effective for panic disorder, they are not FDA-approved specifically for this indication and generally have less favorable side effect profiles compared to SSRIs 7.