What are the typical medications and dosages used to manage anxiety?

Medications and Dosages for Anxiety Management

First-Line Treatment: SSRIs

SSRIs are the first-line pharmacotherapy for anxiety disorders, with sertraline being the most extensively studied and FDA-approved option. 1, 2, 3

Sertraline Dosing (FDA-Approved)

• Initial dose: 25 mg once daily for panic disorder, PTSD, and social anxiety disorder 2
• Therapeutic dose: Increase to 50 mg once daily after one week 2
• Dose range: 50-200 mg/day, with adjustments no more frequently than weekly intervals 2
• For generalized anxiety disorder: Start at 50 mg once daily 2

Other SSRIs

• Fluoxetine, fluvoxamine, paroxetine, citalopram, and escitalopram are also effective, though specific dosing varies by agent 1
• Most SSRIs permit once-daily dosing due to long half-lives, except sertraline at low doses and fluvoxamine may require twice-daily dosing 1
• Citalopram/escitalopram have the lowest propensity for drug interactions via CYP450 enzymes 1

SSRI Titration Strategy

• Start with a subtherapeutic "test" dose to assess tolerability, as initial anxiety/agitation can occur 1
• Increase in smallest available increments at 1-2 week intervals for shorter half-life SSRIs (sertraline, citalopram) 1
• Increase at 3-4 week intervals for longer half-life SSRIs (fluoxetine) 1
• Clinical improvement typically occurs by week 6, with maximal benefit by week 12 1

First-Line Treatment: SNRIs

SNRIs are equally effective as SSRIs for anxiety disorders, with duloxetine being the only FDA-approved SNRI for generalized anxiety disorder in children and adolescents. 1

SNRI Options

• Venlafaxine extended-release and duloxetine have the most evidence 1
• Number needed to treat (NNT) = 4.94 for SNRIs, comparable to SSRIs (NNT = 4.70) 1
• Single daily dosing is possible with extended-release formulations 1

SNRI Monitoring Requirements

• Monitor blood pressure and pulse regularly, as SNRIs can cause sustained hypertension 1
• Check liver function with duloxetine, as hepatic failure can occur (discontinue if jaundice develops) 1
• Watch for severe skin reactions with duloxetine (Stevens-Johnson syndrome risk) 1

Critical Safety Considerations

Black Box Warning

• All SSRIs and SNRIs carry a black box warning for suicidal thinking/behavior through age 24 1
• Pooled absolute risk: 1% with antidepressants vs 0.2% with placebo (NNH = 143) 1
• Close monitoring is mandatory, especially in the first months and after dose adjustments 1

Common Adverse Effects

• Early effects (first few weeks): Nausea, diarrhea, headache, insomnia, dizziness, behavioral activation/agitation 1
• Behavioral activation is more common in younger children and with anxiety disorders compared to depression 1
• Discontinuation syndrome can occur with shorter-acting SSRIs (especially paroxetine, fluvoxamine, sertraline) 1

Serious Adverse Effects to Monitor

• Serotonin syndrome (contraindicated with MAOIs) 1
• QT prolongation with citalopram at doses >40 mg/day 1
• Abnormal bleeding, seizures, sexual dysfunction, hypomania/mania 1

Second-Line Treatment Options

Buspirone (Non-Controlled)

• Initial dose: 5 mg twice daily 4
• Maximum dose: 20 mg three times daily 4
• Onset: Takes 2-4 weeks to become fully effective 4
• Best for: Mild to moderate anxiety symptoms 4

Benzodiazepines

• Alprazolam, clonazepam, bromazepam are recommended as second-line for rapid anxiety relief 5
• Not recommended for routine use due to dependence potential 6

Pregabalin and Gabapentin

• Pregabalin has demonstrated efficacy as second-line treatment 5
• Gabapentin is particularly useful for patients with comorbid pain conditions 4, 5

Beta Blockers (Propranolol)

• Best for situational anxiety with prominent somatic symptoms (tremor, tachycardia, sweating) 4
• Not recommended as primary treatment for social anxiety disorder 4
• Use caution in patients with asthma, diabetes, or cardiac conditions 4

Combination Treatment

Combination therapy (SSRI + CBT) is superior to monotherapy for children and adolescents with anxiety disorders. 1

• Combination CBT plus sertraline improved anxiety symptoms, global function, response rates, and remission compared to either treatment alone (moderate strength of evidence) 1
• Regular monitoring by a physician with anxiety expertise is essential for evaluating treatment response 5

Maintenance Treatment Duration

• Continue medications for 6-12 months after remission for generalized anxiety disorder and panic disorder 2, 6
• PTSD requires several months or longer of sustained therapy (demonstrated efficacy for 28 weeks) 2
• Social anxiety disorder may require several months beyond initial response (efficacy demonstrated for 24 weeks) 2
• Avoid abrupt discontinuation to prevent rebound symptoms 4