What are the first-line medications for a patient experiencing anxiety?

First-Line Medications for Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line pharmacological treatments for patients experiencing anxiety disorders. 1

First-Line Medication Options

SSRIs

• SSRIs are considered first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder 1
• Specific SSRIs with evidence for anxiety treatment include:
  • Sertraline - demonstrates both antidepressant and antianxiety effects with a favorable safety profile 2
  • Paroxetine - covered by national health insurance for social anxiety disorder in some countries 3
  • Fluvoxamine - effective for anxiety disorders but has greater potential for drug-drug interactions 3
  • Escitalopram - recommended as first-line in multiple guidelines with potentially fewer drug interactions 3
  • Citalopram - effective but requires caution due to potential QT prolongation at doses exceeding 40 mg/day 3

SNRIs

• Venlafaxine (extended release) is suggested as a first-line medication for anxiety disorders 3, 1
• SNRIs have demonstrated efficacy comparable to SSRIs in treating anxiety disorders 1

Medication Selection Considerations

Efficacy

• Meta-analyses show SSRIs and SNRIs are associated with small to medium effect sizes compared to placebo:
  • For generalized anxiety disorder: standardized mean difference of -0.55 1
  • For social anxiety disorder: standardized mean difference of -0.67 1
  • For panic disorder: standardized mean difference of -0.30 1

Safety Profile

• SSRIs with fewer drug interactions (citalopram/escitalopram) may have lower propensity for drug-drug interactions 3
• Paroxetine has been associated with increased risk of suicidal thinking compared to other SSRIs 3
• Concomitant administration of any SSRIs with monoamine oxidase inhibitors (MAOIs) is contraindicated due to risk of serotonin syndrome 3, 4

Common Side Effects

• SSRIs may cause initial anxiety or agitation, so starting with a subtherapeutic "test" dose may be advisable 3
• Common side effects include:
  • Gastrointestinal effects (nausea, diarrhea) 5
  • Central nervous system effects (headache, insomnia) 5
  • Sexual dysfunction 5

Special Considerations

Discontinuation

• Some SSRIs (particularly paroxetine, fluvoxamine, and sertraline) have been associated with discontinuation syndrome 3
• Symptoms may include dizziness, fatigue, headaches, nausea, insomnia, and anxiety 3
• Long-term SSRI use increases risk of tachyphylaxis and discontinuation syndrome 5

Dosing Recommendations

• Start with lower doses and increase gradually:
  • For shorter half-life SSRIs (sertraline, citalopram): increase at 1-2 week intervals 3
  • For longer half-life SSRIs (fluoxetine): increase at 3-4 week intervals 3
• Faster titration may be indicated for more severe anxiety presentations 3

Treatment Duration

• Anxiety disorders often require long-term treatment 6, 5
• Remission is attainable but can take several months 6
• Stopping medication increases risk of relapse within the first year of initiating treatment 6
• Periodic monitoring is recommended to reassess the risk-benefit ratio of continuing SSRI treatment 5

Combination Therapy

• Combination treatment (CBT and an SSRI) could be offered preferentially over monotherapy for optimal outcomes 3
• Cognitive behavioral therapy (CBT) has strong evidence of efficacy for anxiety disorders and can be considered as a first-line treatment alongside medication 1