How to treat a patient with acute onset increased anxiety with panic?

Treatment of Acute Onset Increased Anxiety with Panic

For acute panic attacks, benzodiazepines such as lorazepam or midazolam are the recommended first-line treatment due to their rapid onset of action and effectiveness in immediately controlling symptoms. 1

Immediate Management

Pharmacological Intervention

• Administer benzodiazepines as monotherapy for acute agitation and panic 1

  • Lorazepam: 1 mg subcutaneous or intravenous immediately (up to 2 mg maximum) 2
  • Can also be given orally or sublingually 2
  • Use lower doses (0.25-0.5 mg) in older or frail patients, or if co-administered with antipsychotics 2

• Alternative: Midazolam 2.5 mg subcutaneous or intravenous every 1 hour as needed (up to 5 mg maximum) 2

  • Use lower doses (0.5-1 mg) in elderly, frail, or COPD patients 2

Non-Pharmacological Measures

• Provide reassurance to the patient and family members - anxiety is a natural response and reassurance is of great importance 2
• Ensure a calm environment and remove triggering stimuli when possible 2
• Administer oxygen (2-4 L/min) if the patient is breathless or shows signs of respiratory distress 2

Important Caveats

Benzodiazepine Risks

• Increased risk of falls - use caution in elderly patients 2
• May paradoxically cause agitation, anxiety, or delirium in some patients 2
• Contraindicated in severe pulmonary insufficiency, severe liver disease, and myasthenia gravis (unless patient is imminently dying) 2
• Respiratory depression may occur; have naloxone available if using with opioids 2

When Benzodiazepines Are Insufficient

• If anxiety persists despite benzodiazepines, consider adding an antipsychotic such as haloperidol (0.5-1 mg) or risperidone (0.5 mg orally) 2
• Avoid combining high-dose olanzapine with benzodiazepines - fatalities have been reported 2

Transition to Definitive Treatment

For Ongoing Panic Disorder Management

Once the acute episode is controlled, transition to evidence-based long-term treatment:

• SSRIs (sertraline, escitalopram, fluoxetine) or SNRIs (venlafaxine extended release) are first-line for ongoing panic disorder 2, 3

  • These medications show small to medium effect sizes compared to placebo (SMD -0.30,95% CI -0.37 to -0.23) 3
  • Sertraline is FDA-approved for panic disorder in adults 4

• Cognitive behavioral therapy (CBT) should be offered as it demonstrates efficacy for panic disorder with small to medium effect size (Hedges g = 0.39,95% CI 0.12 to 0.65) 3

  • CBT is the psychotherapy with the most evidence for anxiety disorders 2, 3

Short-Term Benzodiazepine Use

• If benzodiazepines are continued beyond the acute episode, use alprazolam 0.25-0.5 mg orally three times daily as initial dosing for anxiety 2, 5

  • For panic disorder specifically, may require titration up to 1-10 mg daily (mean 5-6 mg/day) 5
  • Limit duration to 2-4 weeks maximum when possible to minimize dependence risk 6, 7

• Taper gradually when discontinuing - decrease by no more than 0.5 mg every 3 days, or slower if needed 5

  • Abrupt discontinuation should be avoided due to withdrawal risk 5

Long-Term Considerations

• Maintenance treatment for panic disorder is recommended for at least 12-24 months, and in some cases indefinitely 8
• SSRIs/SNRIs are preferred over benzodiazepines for long-term management due to better safety profile, lack of physical dependency, and relative safety in overdose 8
• Long-term benzodiazepine use is only justified when symptomatic relief and improved functioning outweigh dependence risk 7