What medication helps with panic attacks without increasing intraocular pressure?

Medications for Panic Attacks That Don't Increase Eye Pressure

SSRIs (particularly sertraline) are the best medications for panic attacks that don't increase intraocular pressure, offering effective symptom control while avoiding the eye pressure concerns associated with benzodiazepines.

First-Line Treatment Options

• SSRIs (Selective Serotonin Reuptake Inhibitors) are recommended as first-line pharmacotherapy for panic attacks and do not increase intraocular pressure 1, 2
• Sertraline specifically has demonstrated excellent efficacy in panic disorder with a favorable side effect profile that doesn't affect eye pressure 3, 4
• SSRIs have shown good evidence of efficacy in reducing panic symptoms, with paroxetine and fluoxetine demonstrating stronger evidence than sertraline, though all are effective 1
• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) like venlafaxine are also effective for panic disorder without increasing eye pressure 1, 2

Medications to Avoid

• Beta-blockers (like timolol, propranolol) should be avoided as they can reduce intraocular pressure and are used specifically to treat glaucoma 5
• Benzodiazepines (like alprazolam, diazepam, clonazepam) show high efficacy for panic attacks but should be used cautiously as they may increase risk of angle closure glaucoma in predisposed individuals 5, 1
• Tricyclic antidepressants may have anticholinergic effects that could potentially increase intraocular pressure in susceptible individuals 1, 2

Efficacy Considerations

• In network meta-analyses, SSRIs demonstrated significant efficacy over placebo with a number needed to treat of 7 (meaning seven people need treatment for one to benefit) 2
• Escitalopram has shown effectiveness in panic disorder with a faster onset of action than some other SSRIs and good long-term efficacy 6
• Sertraline has demonstrated equivalent efficacy to paroxetine in direct comparison studies but with better tolerability and less clinical worsening during medication tapering 4

Treatment Algorithm

1. Start with an SSRI (sertraline 25-50mg daily, titrating up to 50-150mg as needed) 3, 4
2. If inadequate response after 4-6 weeks at therapeutic dose:
   • Consider switching to another SSRI (escitalopram 10-20mg daily) 6
   • Or switch to an SNRI like venlafaxine 1
3. For severe, treatment-resistant cases only:
   • Consider short-term, supervised use of a benzodiazepine with careful monitoring of eye pressure in patients with glaucoma risk factors 1

Special Considerations

• Patients with glaucoma should have regular eye pressure monitoring while on any psychotropic medication 5
• Air travel can potentially affect intraocular pressure in patients with glaucoma, so medication management should be optimized before travel 5
• Cognitive behavioral therapy (CBT) is an effective non-pharmacological treatment option that can be used alone or in combination with medication without any risk of increasing eye pressure 5

Monitoring and Follow-up

• Regular assessment of panic symptoms and medication side effects is essential 1, 2
• For patients with known glaucoma or elevated intraocular pressure, coordination between psychiatrist and ophthalmologist is recommended 5
• Long-term maintenance therapy with SSRIs is often needed to prevent relapse of panic disorder 3, 6