What is the recommended initial medication for anxiety management?

First-Line Medication for Anxiety Management

Selective Serotonin Reuptake Inhibitors (SSRIs) are the recommended first-line pharmacological treatment for anxiety disorders due to their established efficacy and favorable side effect profile. 1, 2

Medication Selection Algorithm

First-Line Options:

• SSRIs should be considered the primary first-line pharmacotherapy for anxiety disorders 1, 2, 3
  • Sertraline (starting at 25-50 mg daily) 4, 5, 6
  • Fluoxetine (starting at 10-20 mg daily) 7, 8
  • Other SSRIs include citalopram, escitalopram, paroxetine, and fluvoxamine 1

Alternative First-Line Options:

• SNRIs are also effective first-line options with similar efficacy to SSRIs 1, 3
  • Duloxetine is the only SNRI with FDA approval for generalized anxiety disorder in children and adolescents 7 years and older 1
  • Venlafaxine has demonstrated efficacy similar to SSRIs (NNT = 4.94 vs. 4.70 for SSRIs) 1

Dosing and Administration

• Start with a low dose and gradually increase as tolerated 1, 2
• Consider beginning with a subtherapeutic "test" dose as SSRIs can initially increase anxiety 1, 2
• For sertraline:
  • Start at 25 mg daily for panic disorder, PTSD, and social anxiety 4
  • Increase to 50 mg after one week 4
  • Maximum dose: 200 mg/day 4
• For fluoxetine:
  • Start at 10 mg daily for panic disorder 7
  • Increase to 20 mg after one week 7
  • Dose range: 20-60 mg/day 7
• Allow 1-2 weeks between dose adjustments for shorter half-life SSRIs (sertraline, citalopram) 1
• Allow 3-4 weeks between dose adjustments for longer half-life SSRIs (fluoxetine) 1

Monitoring and Side Effects

• Most adverse effects emerge within the first few weeks of treatment 1
• Common side effects include dry mouth, nausea, diarrhea, headache, somnolence, insomnia, and sexual dysfunction 1
• Monitor closely for behavioral activation/agitation, especially in the first months of treatment and following dosage adjustments 1
• All SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 years 1

Treatment Considerations

• Combination treatment with CBT and an SSRI may be more effective than either treatment alone 1, 2
• SSRIs have a better safety profile than older antidepressants, with low risk of lethality in overdose 5
• Sertraline has a lower potential for pharmacokinetic drug interactions compared to fluoxetine, fluvoxamine, and paroxetine 5
• After achieving remission, medications should be continued for 6-12 months 3
• For discontinuation, gradually reduce the dose rather than abrupt cessation to minimize withdrawal symptoms 7

Special Populations

• For children and adolescents, parental oversight of medication regimens is crucial 1
• For elderly patients or those with hepatic impairment, consider lower or less frequent dosing 4, 7
• For pregnant women in the third trimester, carefully consider risks and benefits; tapering may be appropriate 7

SSRIs have demonstrated consistent efficacy across multiple anxiety disorders with a favorable side effect profile, making them the preferred initial pharmacological intervention for anxiety management 1, 2, 3, 8.