What are the recommended medications for treating panic attacks?

Recommended Medications for Panic Attacks

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for panic attacks due to their effectiveness, safety profile, and long-term efficacy. 1, 2

First-Line Medications

SSRIs

• Preferred options: Sertraline, escitalopram, fluoxetine, fluvoxamine, paroxetine
• Starting dose: 20 mg once daily for most SSRIs
• Mechanism: Inhibit presynaptic reuptake of serotonin, increasing serotonin availability at synaptic cleft
• Onset: Full therapeutic effect typically takes 4-6 weeks
• Side effects: Dry mouth, nausea, diarrhea, headache, somnolence, insomnia, sexual dysfunction

SNRIs

• Option: Venlafaxine
• Efficacy: Comparable to SSRIs
• Side effects: Similar to SSRIs plus more noradrenergic effects (increased blood pressure, sweating)

Second-Line Medications

Tricyclic Antidepressants (TCAs)

• Options: Clomipramine, imipramine
• Efficacy: As effective as SSRIs but less well tolerated 3
• Limitations: Require cardiac monitoring in patients over 40 years
• Side effects: Drowsiness, weight gain, anticholinergic symptoms

Short-Term/Adjunctive Medications

Benzodiazepines

• Options: Alprazolam, clonazepam, diazepam
• Use: Short-term treatment (1-4 weeks) for breakthrough anxiety during initiation of SSRIs 1, 4
• Caution: Risk of dependence and tolerance; not recommended for long-term use
• Evidence: Alprazolam has proven efficacy in placebo-controlled studies for panic disorder 4
• Dosing: For alprazolam, doses up to 4 mg/day were used in clinical studies, though panic disorder often requires 5-6 mg/day 4

Treatment Algorithm

1. Initial treatment:

   • Start with an SSRI (sertraline or escitalopram) at 20 mg/day
   • Consider adding a benzodiazepine (e.g., alprazolam) for the first 2-4 weeks only while waiting for SSRI effect

2. After 4-6 weeks:

   • If good response: Continue SSRI for at least 24-28 weeks after initial response
   • If partial response: Increase SSRI dose within recommended range
   • If no response: Switch to another SSRI or an SNRI

3. For treatment-resistant cases:

   • Consider TCA (clomipramine or imipramine)
   • Consider combination therapy with CBT

Important Considerations

Duration of Treatment

• Continue treatment for at least 24-28 weeks after initial response
• Gradual tapering essential when discontinuing medications to avoid withdrawal symptoms

Potential Pitfalls

• Inadequate duration: Premature discontinuation increases relapse risk
• Abrupt discontinuation: Can cause withdrawal symptoms, particularly with benzodiazepines and SSRIs
• Overlooking comorbidities: Address concurrent depression or substance use disorders

Special Populations

• Children/adolescents (6-18 years): SSRIs are recommended for anxiety disorders including panic disorder 5
• Elderly patients: Use lower starting doses and slower titration
• Hepatic/renal impairment: Use caution, particularly with paroxetine

Combination with Psychotherapy

• Cognitive Behavioral Therapy (CBT) combined with medication is the most successful treatment strategy for panic disorder 6
• CBT typically consists of 14 individual sessions over 4 months, each session lasting 60-90 minutes 1

The evidence strongly supports SSRIs as first-line treatment for panic attacks, with benzodiazepines reserved for short-term use only due to dependence risk, despite their rapid onset of action 7, 2.