What is the best medication for treating panic attacks?

Best Medication for Panic Attacks

SSRIs, particularly sertraline, are the best first-line medication for panic disorder, with FDA approval and strong evidence for efficacy and safety. 1

First-Line Pharmacological Treatment

SSRIs are the recommended first-line medication class for panic disorder based on their superior benefit-to-risk profile. 2, 3 Among SSRIs, sertraline has the strongest evidence base with FDA approval specifically for panic disorder. 1

Why SSRIs Are Preferred

• Efficacy: SSRIs demonstrate a number needed to treat (NNT) of 4.70 for anxiety disorders, meaning approximately 1 in 5 patients will respond to treatment who would not have responded to placebo. 2, 3

• Safety profile: SSRIs have dropout rates similar to placebo, indicating good tolerability. 2, 3 They do not cause physical dependence, unlike benzodiazepines. 4

• Long-term use: SSRIs are safe for extended treatment, which is essential since panic disorder requires maintenance therapy for 12-24 months minimum. 4

Specific SSRI Recommendations

Sertraline is the most evidence-based choice among SSRIs for panic disorder:

• FDA-approved specifically for panic disorder with or without agoraphobia 1
• Demonstrated superiority over placebo in reducing panic attack frequency, Clinical Global Impression scores, and quality of life measures 5
• Effective dose range: 50-200 mg/day, with most patients responding to 50-175 mg/day 6
• Provides relapse prevention for up to 36 weeks following withdrawal 6

Other effective SSRIs include paroxetine, fluoxetine, and fluvoxamine, all with moderate strength of evidence. 2 Paroxetine and fluoxetine appear to have stronger evidence than sertraline within the SSRI class based on comparative data. 7

Alternative First-Line Option: SNRIs

Venlafaxine (an SNRI) is an alternative first-line option with similar efficacy to SSRIs (NNT = 4.94) and comparable dropout rates to placebo. 2, 3 However, evidence for SNRIs is more limited and primarily based on venlafaxine studies. 2

Role of Benzodiazepines

Benzodiazepines should NOT be first-line treatment despite their rapid onset of action. Here's the critical distinction:

When Benzodiazepines May Be Considered

• Acute panic attacks: Alprazolam and diazepam show the strongest evidence for rapid symptom relief and were ranked highest for efficacy and tolerability in acute treatment. 7
• Short-term adjunctive use: May be used temporarily while waiting for SSRI onset (which takes 2-6 weeks for clinical benefit). 2

Why Benzodiazepines Are Not First-Line

• Dependence risk: Benzodiazepines cause tolerance and physical dependency with chronic use. 4, 8
• Not suitable for long-term management: Panic disorder requires extended treatment, making dependence-forming medications problematic. 4
• Withdrawal complications: Discontinuation can be difficult and may worsen anxiety. 8

Practical Implementation Algorithm

Starting SSRI Treatment

1. Begin with sertraline 25 mg daily as a test dose to assess for initial anxiety exacerbation (a known early SSRI side effect). 2

2. Increase to 50 mg daily after 3-7 days if tolerated. 1, 6

3. Titrate slowly at 1-2 week intervals for shorter half-life SSRIs (sertraline, paroxetine) or 3-4 week intervals for longer half-life SSRIs (fluoxetine). 2

4. Target dose range: 50-200 mg/day for sertraline, adjusting based on response and tolerability. 1, 6

5. Expect clinical improvement by week 6 with maximal benefit by week 12. 2

Monitoring and Safety

• Monitor for suicidal ideation, particularly in the first few weeks of treatment and in patients under age 24 (boxed warning applies). 2, 3

• Common side effects include nausea, diarrhea, headache, insomnia, sexual dysfunction, and initial anxiety worsening. 2

• Serious but rare adverse effects include serotonin syndrome (especially with drug combinations), seizures, and abnormal bleeding. 2, 3

Treatment Duration

• Continue treatment for minimum 12-24 months after achieving remission. 4
• Some patients may require indefinite treatment depending on illness severity and relapse history. 4
• Taper slowly when discontinuing to avoid discontinuation syndrome, particularly with shorter half-life SSRIs like paroxetine. 2

Combination Treatment Consideration

Adding CBT to SSRI treatment provides superior outcomes compared to medication alone, particularly for long-term response. 2 The combination of sertraline plus CBT showed the strongest evidence for improved response rates and remission. 2

Key Clinical Pitfalls to Avoid

• Don't start at full therapeutic doses: Initial anxiety exacerbation is common with SSRIs; start low and titrate slowly. 2

• Don't discontinue prematurely: Patients may not see benefit until 6-12 weeks; counsel about delayed onset. 2

• Don't use benzodiazepines as monotherapy: While effective acutely, they are inappropriate for long-term management due to dependence risk. 4, 8

• Don't forget drug interactions: Sertraline affects CYP2D6; fluvoxamine has extensive CYP450 interactions. 2