What is the best medication for treating panic attacks?

Best Medication for Panic Attacks

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

First-Line Treatment Options

SSRIs

• Sertraline (Zoloft)

  • Starting dose: 25-50 mg daily
  • Can be titrated up to 200 mg daily
  • FDA-approved for panic disorder 3
  • Demonstrated superior efficacy compared to placebo in reducing panic attack frequency 4
  • Long-term studies show sustained efficacy and protection from relapse for up to 36 weeks 5

• Other SSRIs

  • Escitalopram: 10 mg daily, can increase to 20 mg daily
  • Fluoxetine: 20 mg daily, can increase to 40-50 mg daily 6

Mechanism and Timeframe

• SSRIs inhibit presynaptic reuptake of serotonin, increasing serotonin availability at the synaptic cleft 7
• Full therapeutic effect typically takes 4-6 weeks
• Patients should be monitored regularly during this period 6

Short-Term/Adjunctive Options

Benzodiazepines

• Alprazolam
  • FDA-approved for panic disorder 8
  • Provides rapid symptom relief
  • Should be limited to short-term use (1-4 weeks) due to risk of dependence and tolerance 6, 9
  • Can be used as adjunctive therapy during initiation of SSRIs to manage breakthrough anxiety 6

Important Cautions with Benzodiazepines

• Not recommended for long-term management
• Should be avoided in patients with history of substance abuse
• Requires gradual tapering when discontinuing to prevent withdrawal symptoms 6

Treatment Duration and Discontinuation

• Continue effective medication for at least 6-12 months after symptom remission 6
• Optimal maintenance is 24-28 weeks after initial response 6
• When discontinuing, taper gradually:
  • For SSRIs: Reduce by no more than 10 mg every 1-2 weeks
  • For benzodiazepines: Even more gradual tapering is essential 6

Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT) is highly effective for panic disorder
  • Typically 14 sessions over 4 months
  • Key components: psychoeducation, cognitive restructuring, exposure therapy, relaxation techniques 6
• Combining CBT with medication (particularly SSRIs) provides superior outcomes compared to either treatment alone 6

Special Considerations

• Elderly patients: Use lower starting doses and slower titration 6
• Hepatic/renal impairment: Use caution, especially with paroxetine 6
• Monitoring: Assess for suicidal ideation, particularly during first few weeks of SSRI treatment and after dose changes 6
• Common pitfall: Premature discontinuation increases relapse risk 6

Treatment Algorithm

1. Start with sertraline 25-50 mg daily (or another SSRI if preferred)
2. Consider short-term benzodiazepine (e.g., alprazolam) for immediate symptom relief during first 2-4 weeks
3. Gradually increase SSRI dose if needed after 4-6 weeks
4. Add CBT when possible for optimal outcomes
5. Continue treatment for at least 6-12 months after symptom remission
6. Taper medication gradually when discontinuing

This approach balances immediate symptom relief with long-term efficacy and safety considerations, addressing both the acute distress of panic attacks and the need for sustained remission.