From the Guidelines
The most appropriate initial pharmacological treatment for panic disorder is a selective serotonin reuptake inhibitor (SSRI) such as sertraline, escitalopram, or fluoxetine, as they have been shown to be effective in reducing the frequency and severity of panic attacks with a favorable side effect profile 1.
Key Considerations
- Treatment should begin at a low dose and gradually increase over several weeks to minimize side effects, with therapeutic effects typically appearing after 4-6 weeks.
- SSRIs should be continued for at least 6-12 months after symptom resolution to prevent relapse.
- During the initial weeks of treatment, benzodiazepines like clonazepam may be used short-term (2-4 weeks) to provide immediate symptom relief while waiting for the SSRI to take effect.
- Patients should be informed about potential initial side effects such as nausea, headache, and increased anxiety, which typically resolve within the first few weeks of treatment.
Evidence-Based Recommendations
- The Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology clinical practice guideline for social anxiety disorder suggests fluvoxamine, paroxetine, and escitalopram as first-choice treatments, which are also applicable to panic disorder 1.
- A systematic review of trials of antianxiety medications in adults indicated no differences in discontinuation between treatment and placebo groups, supporting the use of SSRIs as a first-line treatment 1.
- The effectiveness of SSRIs in reducing anxiety symptoms has been consistently demonstrated in systematic reviews of psychological and pharmacologic therapies 1.
From the FDA Drug Label
The target dose of PAXIL in the treatment of panic disorder is 40 mg/day Patients should be started on 10 mg/day. Dose changes should occur in 10-mg/day increments and at intervals of at least 1 week.
The most appropriate initial pharmacological treatment of panic disorder is paroxetine (PAXIL), starting with a dose of 10 mg/day and titrating up to a target dose of 40 mg/day in 10-mg/day increments, with dose changes occurring at intervals of at least 1 week 2.
From the Research
Initial Pharmacological Treatment of Panic Disorder
The most appropriate initial pharmacological treatment of panic disorder includes:
- Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, citalopram, escitalopram, fluoxetine, and fluvoxamine, which have been proven to be superior to placebo in reducing panic attack frequency and improving associated symptoms 3, 4, 5
- Serotonin-norepinephrine reuptake inhibitors (SNRIs), which are also effective in treating panic disorder 4
- Tricyclic antidepressants, although they are less well-tolerated than SSRIs and SNRIs 4
- Benzodiazepines, such as alprazolam, which may be used for short-term treatment or in non-responsive cases, but with caution due to the risk of dependency and tolerance 4, 6
Key Characteristics of Paroxetine
Paroxetine is a highly selective inhibitor of presynaptic serotonin reuptake and has been shown to be:
- Effective in reducing panic attack frequency and improving associated symptoms in patients with panic disorder with or without agoraphobia 3, 7
- Well-tolerated, with a tolerability profile similar to that of other SSRIs, and a lower incidence of certain anticholinergic events compared to tricyclic antidepressants 3
- Associated with a lower risk of relapse when used for long-term treatment 3, 7
Treatment Recommendations
Combining drug treatment with cognitive behavior therapy is the most successful treatment strategy for panic disorder 4. Treatment guidelines recommend continuing pharmacotherapy, such as paroxetine, for at least 1 year to maintain efficacy and reduce the risk of relapse 7.