What are the recommended medications and dosages for a patient with anxiety?

Medications for Anxiety

First-Line Pharmacotherapy

SSRIs (escitalopram or sertraline) and SNRIs (venlafaxine or duloxetine) are the recommended first-line medications for anxiety disorders, with escitalopram and sertraline preferred due to their superior efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms. 1

Preferred SSRI Options and Dosing

• Escitalopram: Start 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, target dose 10-20 mg/day (maximum 20 mg/day due to QTc prolongation risk at higher doses) 1, 2

• Sertraline: Start 25-50 mg daily for anxiety disorders (panic disorder, PTSD, social anxiety), increase by 25-50 mg increments every 1-2 weeks, target dose 50-200 mg/day 1, 3

• Escitalopram has the least CYP450 enzyme interactions among SSRIs, making it safer for patients on multiple medications 1

• Paroxetine and fluvoxamine are equally effective but carry higher risks of discontinuation syndrome and should be reserved for when first-tier SSRIs fail 1

SNRI Alternatives

• Venlafaxine extended-release: Start 75 mg daily, titrate to 75-225 mg/day; requires blood pressure monitoring due to risk of sustained hypertension 1, 4

• Duloxetine: Start 30 mg daily for one week to minimize nausea, then increase to 60-120 mg/day; particularly beneficial for patients with comorbid pain conditions 1

Expected Response Timeline and Monitoring

• Week 2: Statistically significant improvement may begin 1

• Week 6: Clinically significant improvement expected 1

• Week 12 or later: Maximal therapeutic benefit achieved 1

• Use standardized anxiety rating scales (GAD-7 or HAM-A) to objectively track response every 2-4 weeks 1

• If inadequate response after 8-12 weeks at therapeutic doses, switch to a different SSRI or SNRI, or add cognitive behavioral therapy 1

Critical Safety Warnings

• Suicidal ideation: Monitor closely during the first 1-2 months and after dose changes; pooled risk is 1% vs 0.2% for placebo (NNH = 143) 1

• Common side effects (emerge within first few weeks, typically resolve): nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, dizziness 1

• Discontinuation syndrome: Taper gradually when stopping, particularly with shorter half-life SSRIs (paroxetine, sertraline); escitalopram has lower risk 1

Second-Line Medications

• Pregabalin/Gabapentin: Consider when first-line treatments fail or are not tolerated, particularly effective for patients with comorbid pain 1

• Buspirone: Alternative for mild-to-moderate generalized anxiety when SSRIs are contraindicated; dose 5 mg twice daily, titrate to 20 mg three times daily over 2-4 weeks 5

Medications to Avoid

• Benzodiazepines (alprazolam, lorazepam): Reserve only for short-term use or acute anxiety management due to risks of dependence, tolerance, withdrawal, and cognitive impairment 1, 6

• Tricyclic antidepressants: Avoid due to unfavorable risk-benefit profile, particularly cardiac toxicity 1

• Beta blockers (atenolol, propranolol): Not recommended for social anxiety disorder based on negative evidence 1

Combination Treatment Strategy

Combining SSRI/SNRI with cognitive behavioral therapy provides superior outcomes compared to medication alone, with large effect sizes (Hedges g = 1.01 for GAD). 1, 7

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1

• Recommend 12-20 structured CBT sessions targeting anxiety-specific elements: psychoeducation, cognitive restructuring, relaxation techniques, and gradual exposure 1

• Combination therapy is particularly beneficial for moderate-to-severe anxiety or when monotherapy provides inadequate response 1

Treatment Duration

• Continue effective medication for minimum 9-12 months after achieving remission to prevent relapse 1

• For first episode: 6-12 months continuation therapy 8

• For recurrent anxiety (2+ episodes): Consider years to lifelong maintenance therapy 1

• Reassess monthly until symptoms stabilize, then every 3 months 1

Common Pitfalls to Avoid

• Premature switching: Allow full 8-12 weeks at therapeutic dose before declaring treatment failure 1

• Inadequate dosing: Start low but titrate to therapeutic range; most patients require 50-200 mg sertraline or 10-20 mg escitalopram 1, 3

• Too-rapid titration: Increase doses every 1-2 weeks minimum to minimize activation symptoms and allow assessment of tolerability 1

• Prescribing benzodiazepines as first-line: These should be time-limited only, not routine treatment 1

• Ignoring psychotherapy: Medication alone is less effective than combination treatment for most patients 1, 7