Recommended Drug for Acute Panic Attack
Alprazolam (a benzodiazepine) is the recommended drug for an acute panic attack due to its rapid onset of action and proven efficacy in immediately controlling panic symptoms. 1
Rationale for Benzodiazepines in Acute Settings
For acute panic attacks requiring immediate symptom relief, benzodiazepines—particularly alprazolam—are the treatment of choice because they provide rapid anxiolytic effects within minutes to hours, unlike SSRIs which require weeks to achieve therapeutic benefit. 2, 3
Key Evidence Supporting Alprazolam:
Alprazolam demonstrated superior efficacy in reducing panic attack frequency to zero in clinical trials, with 37-83% of patients achieving complete panic attack cessation. 1
Benzodiazepines ranked highest for tolerability and were associated with lower dropout rates compared to placebo and other medication classes in network meta-analysis. 3
Alprazolam and clonazepam showed the strongest reduction in frequency of panic attacks compared to placebo and ranked highest among all medications studied. 3
Rapid onset of action distinguishes benzodiazepines from antidepressants, making them ideal for acute panic episodes where immediate relief is critical. 2, 4
Why SSRIs Are NOT Appropriate for Acute Panic
Fluoxetine, sertraline, and paroxetine (options A, B, and D) are NOT appropriate for acute panic attacks because they:
Require several weeks (4-8 weeks) to achieve therapeutic effect, making them unsuitable for immediate symptom control. 2, 5
Can initially exacerbate anxiety and panic early in the treatment course, potentially worsening the acute episode. 2
Are indicated for long-term maintenance treatment of panic disorder (12-24 months or indefinitely), not acute episodes. 5
Clinical Context and Guidelines
WHO guidelines recommend psychological treatment based on CBT principles for people concerned about prior panic attacks, but do not specifically address pharmacological management of acute episodes. 6
For acute agitation in emergency settings, benzodiazepines (lorazepam or midazolam) are recommended as effective monotherapy. 6
Important Caveats
Limitations of Benzodiazepines:
Risk of tolerance and dependence develops with chronic use, limiting their role to acute management rather than long-term treatment. 2, 4
Physical and emotional dependence can occur even at recommended doses, particularly at doses >4 mg/day. 1
Withdrawal symptoms and seizures can occur with abrupt discontinuation, requiring careful tapering. 1
Transition to Long-Term Treatment:
After acute stabilization with alprazolam, transition to an SSRI (such as paroxetine or sertraline) for long-term management and prevention of recurrent panic attacks. 7, 4, 5
Combined treatment with benzodiazepines initially plus SSRIs may provide optimal outcomes—immediate relief from benzodiazepines while SSRIs reach therapeutic levels, then benzodiazepine taper. 2, 4
Answer to Question
C. Alprazolam is the correct answer for acute panic attack management due to its rapid onset, proven efficacy in panic disorder, and superior tolerability profile among acute treatments. 1, 3
The other options (fluoxetine, sertraline, paroxetine) are appropriate for long-term maintenance treatment but ineffective for acute episodes requiring immediate intervention. 2, 7, 5