What is the drug of choice for anxiety disorder?

From the Guidelines

The first-line drug of choice for anxiety disorders is typically a selective serotonin reuptake inhibitor (SSRI) such as sertraline (50-200 mg daily), escitalopram (10-20 mg daily), or fluoxetine (20-80 mg daily). These medications are preferred because they effectively reduce anxiety symptoms with a favorable side effect profile and are not habit-forming. Treatment should continue for at least 6-12 months after symptom improvement to prevent relapse. For acute anxiety symptoms, benzodiazepines like lorazepam (0.5-2 mg) or alprazolam (0.25-1 mg) may be used short-term (2-4 weeks maximum) due to their rapid onset, but they carry risks of dependence and tolerance. SSRIs work by increasing serotonin levels in the brain, which helps regulate mood and anxiety. They typically take 2-4 weeks to show full therapeutic effects, so patients should be counseled about this delay and potential initial side effects like nausea or increased anxiety that usually resolve within the first two weeks of treatment. Non-pharmacological approaches like cognitive behavioral therapy should be considered alongside medication for optimal outcomes. According to the most recent study 1, SSRIs had a high response rate, with number needed to treat (NNT) = 4.70, and a similar rate of treatment discontinuation as placebo. The response rate for SNRIs was NNT = 4.94, which was similar to SSRIs. The dropout rate was similar to placebo, suggesting a high safety profile. Some key points to consider when choosing a medication for anxiety include:

• The medication's efficacy in reducing anxiety symptoms
• The medication's side effect profile
• The patient's medical history and current medications
• The potential for dependence and tolerance
• The cost and availability of the medication As stated in the study 1, the drugs covered by national health insurance for social anxiety disorder in Japan are fluvoxamine, paroxetine, and escitalopram, which are suggested as first choice. It's also important to note that, as mentioned in the study 1, venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is suggested as a treatment option for social anxiety disorder, although the strength of recommendation is weak and the certainty of evidence is low. In terms of dosing, the study 1 mentions that venlafaxine extended release, desvenlafaxine, and duloxetine have sufficiently long elimination half-lives to permit single daily dosing. Overall, the choice of medication for anxiety should be individualized based on the patient's specific needs and circumstances.

From the FDA Drug Label

The recommended starting dose of Escitalopram tablets is 10 mg once daily. If the dose is increased to 20 mg, this should occur after a minimum of one week. The efficacy of Escitalopram in the acute treatment of Generalized Anxiety Disorder (GAD) was demonstrated in three, 8-week, multicenter, flexible-dose, placebo-controlled studies that compared Escitalopram 10-20 mg/day to placebo in adult outpatients between 18 and 80 years of age who met DSM-IV criteria for GAD

Escitalopram is a potential drug of choice for anxiety, specifically for Generalized Anxiety Disorder (GAD), with a recommended starting dose of 10 mg once daily 2. The efficacy of Escitalopram in the treatment of GAD has been demonstrated in several studies, showing statistically significant greater mean improvement compared to placebo on the Hamilton Anxiety Scale (HAM-A) 2.

From the Research

Drug of Choice for Anxiety

The choice of drug for anxiety depends on various factors, including the type of anxiety disorder, patient age, and co-morbidities.

• For panic disorder, selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are commonly prescribed 3, 4.
• SSRIs, such as escitalopram and venlafaxine, have been shown to be effective in treating panic disorder, with a delayed onset of action but fewer risks of dependence and tolerance 3, 4.
• Benzodiazepines, on the other hand, have a rapid onset of action but can cause tolerance and dependence 3, 4.
• For generalized anxiety disorder (GAD), SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) are recommended as first-line treatments, with benzodiazepines and other medications considered as second-line options 5, 6.
• A network meta-analysis found that duloxetine and escitalopram showed better efficacy in treating GAD, while vortioxetine showed better acceptability 6.
• Another study found that escitalopram, venlafaxine, and benzodiazepines had greater efficacy and acceptability than placebo in treating panic disorder 4.

Factors Influencing Drug Choice

The choice of drug for anxiety also depends on patient-specific factors, such as:

• Age: SSRIs are recommended as first-line treatment for pediatric patients with GAD, while adults may be treated with SSRIs, SNRIs, or benzodiazepines 5.
• Co-morbidities: Patients with co-morbid depression or other anxiety disorders may require different treatment approaches 5, 7.
• Prior treatment: Patients who have not responded to previous treatments may require alternative medications or combination therapy 5, 7.