What medication is appropriate for a patient with anxiety and panic attacks?

Medication Management for Anxiety and Panic Attacks

Sertraline 25-50 mg daily is the recommended first-line medication for anxiety with panic attacks, titrated to a target dose of 50-200 mg/day over 4-6 weeks, combined with cognitive behavioral therapy for optimal outcomes. 1, 2

First-Line Pharmacotherapy: SSRIs

Sertraline is the preferred SSRI based on FDA approval for panic disorder, established efficacy, and favorable tolerability profile. 2, 3

• Start sertraline at 25 mg daily for the first week to minimize initial anxiety or agitation, then increase to 50 mg daily after week 1. 1
• Target therapeutic dose is 50-200 mg/day, with most patients responding to 50-150 mg daily. 1, 2, 3
• Single daily dosing is sufficient due to adequate half-life at therapeutic doses. 1

Alternative first-line SSRIs if sertraline is not tolerated:

• Escitalopram 10-20 mg/day 1
• Fluoxetine 20-40 mg/day 1

Avoid paroxetine and fluvoxamine as first-line options due to higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs. 1

Expected Response Timeline and Monitoring

Set realistic expectations for response:

• Statistically significant improvement may begin by week 2 1
• Clinically significant improvement expected by week 6 1
• Maximal therapeutic benefit achieved by week 12 or later 1

Critical monitoring requirements:

• Monitor closely for suicidal thinking and behavior, especially in the first months and after dose changes, with a pooled risk of 1% vs 0.2% placebo (NNH = 143). 1
• Common early side effects include nausea, headache, insomnia, nervousness, and initial anxiety/agitation, which typically resolve with continued treatment. 1, 2

Second-Line Option: SNRIs

Venlafaxine extended-release 75-225 mg/day is an effective alternative if SSRIs fail or are not tolerated. 4, 1

• Requires blood pressure monitoring due to risk of sustained hypertension. 1
• Has lower overall tolerability compared to SSRIs but demonstrated efficacy in panic disorder. 1

Combination with Psychotherapy

Combining sertraline with CBT provides superior outcomes to either treatment alone for panic disorder and generalized anxiety. 1

• Individual CBT is preferred over group therapy for superior clinical and cost-effectiveness. 1
• A treatment course of 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended. 1

Treatment Duration

Continue sertraline for at least 9-12 months after achieving remission to prevent relapse. 1

• Sertraline demonstrated efficacy in maintaining response for up to 28 weeks following initial treatment in relapse prevention trials. 2
• When discontinuing, taper gradually to avoid withdrawal symptoms, particularly important with shorter half-life SSRIs. 1

Critical Pitfalls to Avoid

Do not escalate doses too quickly - allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 1

Do not abandon treatment before 12 weeks - full response requires patience due to the logarithmic response curve of SSRIs. 1

Avoid benzodiazepines as first-line treatment despite alprazolam's FDA approval for panic disorder 5, because they carry risks of dependence, tolerance, and withdrawal, and may paradoxically worsen long-term outcomes. 1, 6

• Reserve benzodiazepines only for short-term use in severe cases while waiting for SSRI onset. 6
• One study found 63% of trauma patients on benzodiazepines developed PTSD versus only 23% on placebo. 1

Algorithm for Treatment Failure

If inadequate response after 8-12 weeks at therapeutic doses:

1. Switch to a different SSRI (e.g., sertraline to escitalopram) 1
2. Consider adding CBT if not already implemented 1
3. If multiple SSRI trials fail, consider venlafaxine (SNRI) 1