What PRN (pro re nata) medication can be used for occasional panic attacks without using a benzodiazepine (benzo)?

Non-Benzodiazepine PRN Medications for Occasional Panic Attacks

Hydroxyzine (25-50 mg orally PRN) is the most practical non-benzodiazepine option for occasional panic attacks, offering rapid anxiolytic effects without the dependence risks of benzodiazepines. 1

Primary Recommendation: Hydroxyzine

Hydroxyzine provides effective anxiolysis for acute anxiety episodes and can be dosed as needed without the addiction potential of benzodiazepines. 1 The typical PRN dosing is 25-50 mg orally, which can be repeated every 4-6 hours as needed. 1

Advantages of Hydroxyzine

• Rapid onset of anxiolytic action without benzodiazepine-related dependence or withdrawal concerns 1
• Can be used on a true PRN basis without tolerance development 1
• Sedating properties help with the acute distress of panic attacks 1

Important Safety Considerations

• Hydroxyzine carries a risk of QT prolongation and should be used cautiously in patients with cardiac risk factors, electrolyte abnormalities, or those taking other QT-prolonging medications 1
• Potentiates CNS depressants including opioids and other sedatives, requiring dose reduction of concomitant medications 1
• May cause drowsiness, requiring caution with driving or operating machinery 1
• Elderly patients should start at lower doses due to increased risk of confusion and oversedation 1
• Rare but serious risk of Acute Generalized Exanthematous Pustulosis (AGEP); discontinue immediately if skin reactions develop 1

Alternative Option: Propranolol

Propranolol (10-40 mg orally PRN) can be effective for panic attacks, particularly when physical symptoms (palpitations, tremor) are prominent. 2 This beta-blocker addresses the peripheral manifestations of anxiety without CNS sedation.

Propranolol Considerations

• Most effective when taken 30-60 minutes before anticipated anxiety-provoking situations 2
• Contraindicated in patients with asthma, COPD, bradycardia, heart block, or uncompensated heart failure 2
• Multiple drug interactions through CYP450 system, particularly with antiarrhythmics, calcium channel blockers, and antidepressants 2
• Less effective for the cognitive/psychological symptoms of panic compared to physical symptoms 2

Why Not Benzodiazepines for PRN Use?

While benzodiazepines show efficacy for panic disorder (RR 1.65 for treatment response), 3 their use carries significant concerns:

• High risk of dependence and withdrawal symptoms, even with intermittent use 4, 3
• Tolerance develops with regular use, requiring dose escalation 4
• Cognitive impairment and psychomotor effects, especially in elderly patients 4
• Guidelines recommend SSRIs as first-line treatment, with benzodiazepines reserved for specific situations 3

Clinical Context and Limitations

The evidence base for non-benzodiazepine PRN medications for panic attacks is limited. Most panic disorder treatment studies focus on scheduled daily medications (SSRIs, SNRIs) rather than PRN interventions. 5, 3

For recurrent panic attacks, scheduled daily treatment with an SSRI or SNRI is more appropriate than relying on PRN medications alone. 5, 3 PRN medications should be considered adjunctive therapy or for truly occasional episodes.

When PRN Approach May Be Insufficient

• Panic attacks occurring more than once weekly typically require scheduled daily medication 5
• Presence of agoraphobia or significant anticipatory anxiety suggests need for maintenance therapy 5
• Comorbid depression or generalized anxiety disorder requires comprehensive treatment approach 5

Practical Implementation

Start with hydroxyzine 25 mg PRN for mild-moderate panic symptoms, increasing to 50 mg if needed. 1 Advise patients to take at first sign of panic symptoms rather than waiting for full-blown attack.

For patients with cardiovascular symptoms as primary complaint, consider propranolol 10-20 mg PRN instead. 2 This requires advance dosing (30-60 minutes before anticipated trigger) for optimal effect.

Monitor for effectiveness after 2-3 PRN uses; if inadequate control or frequent use (>2-3 times weekly), transition to scheduled daily treatment with SSRI. 5, 3