What medications are recommended for a patient experiencing panic attacks?

Medications for Panic Attacks

Cognitive behavioral therapy (CBT) should be the first-line treatment for panic attacks, with SSRIs (specifically sertraline or paroxetine) as the preferred pharmacological option when medication is needed. 1

First-Line Pharmacological Treatment

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are the recommended first-line medications for panic disorder, with sertraline and paroxetine having FDA approval and the strongest evidence base. 2

• Sertraline is FDA-approved for panic disorder treatment in adults, with or without agoraphobia 2

  • Start at 25 mg daily (lower than standard depression dosing) 3
  • Titrate gradually at 1-2 week intervals based on tolerability 3
  • Target dose range: 50-200 mg/day 2, 4
  • Demonstrated significant reduction in panic attack frequency compared to placebo (P=0.01) 4

• Paroxetine is also FDA-approved and highly effective for panic disorder 5

  • Dosing range: 10-60 mg/day 5
  • 51% of patients had no full panic attacks by weeks 7-9 of treatment 5
  • More rapid onset of effect compared to clomipramine 5
  • Important caveat: Paroxetine should generally be avoided in elderly patients due to significant anticholinergic properties and higher rates of adverse effects 3

• Escitalopram is an alternative SSRI with favorable drug interaction profile 3

  • Has the least effect on CYP450 isoenzymes, reducing drug-drug interaction risk 3
  • Particularly useful in patients taking multiple medications 3

Critical Timing Considerations

Expect a 4-6 week delay before therapeutic benefit becomes apparent with SSRIs. 6 During the initial 1-2 weeks of treatment, SSRIs can paradoxically worsen anxiety or cause agitation, which typically resolves spontaneously 3, 7

• Monitor closely during weeks 1-2 for increased anxiety or panic symptoms 3
• Reassure patients this initial activation is temporary and does not indicate treatment failure 7
• Assess treatment response formally at 4 weeks and 8 weeks using standardized instruments 3

Second-Line Pharmacological Options

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine is an appropriate alternative if SSRIs are ineffective or not tolerated. 8

• Demonstrated efficacy across anxiety disorders including panic disorder 8
• Comparable efficacy to SSRIs (NNT = 4.94 vs 4.70 for SSRIs) 8
• Start at low doses and increase gradually to minimize initial anxiety 8

Benzodiazepines: Use with Extreme Caution

Benzodiazepines should NOT be used as first-line treatment for panic disorder despite their rapid onset of action. 1, 7

Why Benzodiazepines Are Not Recommended

• Neither antidepressants nor benzodiazepines should be used for initial treatment of individuals with panic-related complaints 1
• Associated with risk of dependence and withdrawal syndromes 6, 7
• In elderly patients, benzodiazepines increase risk of cognitive impairment, delirium, falls, and fractures 3
• The American Geriatrics Society strongly recommends avoiding benzodiazepines in older adults 3
• Enhanced sensitivity occurs in elderly patients even at low doses 3

Limited Appropriate Use of Benzodiazepines

If benzodiazepines must be used for acute management (which should be rare):

• Use only short half-life agents like lorazepam 3
• In elderly: reduce dose to 0.25-0.5 mg, maximum 2 mg in 24 hours 1, 3
• Avoid combining with opioids due to respiratory depression risk 3
• Plan for discontinuation from the outset 7

Treatment Duration and Maintenance

Continue SSRI treatment for at least 9-12 months after symptom recovery for a first episode. 1

• For recurrent panic disorder, longer-term or indefinite treatment may be necessary 3
• Efficacy is maintained during up to 6 months of treatment 5
• Long-term treatment (52 weeks) demonstrated continued response rates of 85% with paroxetine 5
• Never discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 3

Treatment Algorithm When Initial SSRI Fails

If symptoms are stable or worsening after 8 weeks despite good adherence 3:

1. Switch to a different SSRI with different side effect profile (e.g., from sertraline to escitalopram) 8
2. Switch to an SNRI (venlafaxine) 8
3. Add CBT to pharmacotherapy—combination treatment provides superior outcomes compared to either alone 8

Common Adverse Effects to Monitor

SSRI Side Effects

• Nausea, gastrointestinal disturbances (most common early) 9
• Headaches, somnolence, dry mouth, insomnia 5, 9
• Sexual dysfunction (anorgasmia, ejaculatory dysfunction) for long-term use 9
• Weight gain with prolonged treatment 9
• Rare but serious: serotonin syndrome, neuroleptic malignant syndrome 1

Critical Safety Precautions

• Avoid MAOIs in combination with any serotonergic medications due to serotonin syndrome risk 8
• Monitor for serotonin syndrome symptoms when starting any new serotonergic medication 8
• Review all current medications for potential CYP450 interactions 3
• If using citalopram in patients >60 years old, avoid doses >20 mg daily due to QT prolongation risk 3

Integration with Psychological Treatment

CBT based on psychological principles should be considered as primary treatment for people concerned about prior panic attacks. 1

• CBT has the highest level of evidence for anxiety disorders across all age groups 3
• Individual therapy sessions are generally preferred over group therapy due to superior clinical effectiveness 3
• Combining CBT with SSRI pharmacotherapy provides enhanced effectiveness compared to either treatment alone 8
• If face-to-face CBT is not feasible, self-help CBT with professional support is a viable alternative 3