What is the best medication for a patient experiencing panic attacks with symptoms such as palpitations in crowded places?

Best Medication for Panic Attacks

For acute panic attacks with palpitations in crowded places, lorazepam PRN is the best medication choice among the options provided. 1

Rationale for Lorazepam PRN

Lorazepam is specifically recommended by clinical guidelines for acute panic attacks, with a starting dose of 1 mg subcutaneously or intravenously (or orally/sublingually) for immediate symptom control, with a maximum of 2 mg. 1 This benzodiazepine provides rapid relief of acute panic symptoms including palpitations, which is critical when the patient is experiencing situational panic in crowded places. 1

Evidence Supporting Benzodiazepines for Panic

• Lorazepam has demonstrated comparable efficacy to alprazolam in controlled trials for panic disorder, with significant antipanic effects throughout treatment courses. 2
• Multiple controlled trials confirm that benzodiazepines including lorazepam are clinically effective for the broad range of panic disorder symptoms, with rapid onset of action. 3, 4
• The effect is rapid and maintained without dose increase over extended periods (7-8 months), making it suitable for PRN use during acute episodes. 3

Why Not the Other Options

Quetiapine at Bedtime

Quetiapine is not appropriate for acute panic attacks. While quetiapine appears in guidelines for delirium management with sedating properties 5, it has no established role in panic disorder treatment and would not provide immediate relief for acute panic episodes occurring in public places during daytime hours.

Citalopram Daily

Citalopram (an SSRI) is appropriate for long-term panic disorder management but not for acute attacks. 1 SSRIs have a delayed onset of action (typically 2-4 weeks) and are recommended as first-line treatment for ongoing panic disorder prevention, not for immediate symptom relief. 1 The patient needs immediate relief during acute episodes, which SSRIs cannot provide.

Important Clinical Caveats

Dosing Considerations

• Start with lower doses (0.25-0.5 mg) in elderly or frail patients to minimize fall risk and paradoxical reactions. 1
• The typical effective dose range is 1-2 mg for acute episodes. 1, 2

Safety Warnings

• Increased risk of falls, particularly in elderly patients. 1
• Benzodiazepines may paradoxically cause agitation, anxiety, or delirium in some patients. 1
• Contraindicated in severe pulmonary insufficiency, severe liver disease, and myasthenia gravis (unless patient is imminently dying). 1
• Respiratory depression may occur, especially when combined with opioids. 1

Transition to Definitive Treatment

Lorazepam PRN should be viewed as a bridge to definitive treatment, not a long-term solution. The patient requires:

• SSRIs (sertraline, escitalopram, or citalopram) as first-line maintenance therapy for ongoing panic disorder prevention. 1, 6
• Cognitive Behavioral Therapy (CBT) demonstrates efficacy for panic disorder with small to medium effect size. 1
• Limit benzodiazepine use to 2-4 weeks to minimize dependence risk when used regularly. 1

Practical Implementation

For this patient experiencing situational panic in crowded places:

• Prescribe lorazepam 0.5-1 mg PRN for acute panic symptoms (maximum 2 mg per episode). 1
• Simultaneously initiate an SSRI (citalopram 10-20 mg daily, titrating to therapeutic dose) for long-term management. 1, 6
• Refer for CBT targeting panic disorder and agoraphobic avoidance. 1
• Counsel that lorazepam provides immediate relief but the SSRI will take 2-4 weeks to become effective, at which point PRN benzodiazepine use should decrease. 6