In a 37‑year‑old woman with asthma and stable cyclic vomiting who is taking sertraline 100 mg daily and nortriptyline 10 mg daily and now has panic attacks, is hydroxyzine appropriate as an as‑needed anxiolytic, what dose is recommended, and should the primary care physician reassess nortriptyline before increasing sertraline?

Hydroxyzine for Panic Attacks in a Patient with Asthma

Hydroxyzine is contraindicated in this patient due to her asthma history, and you should instead increase sertraline to 150-200 mg daily for panic disorder while maintaining the current nortriptyline dose.

Critical Safety Concern: Asthma and Sedation

• Any sedation is absolutely contraindicated in patients with asthma 1, 2
• Hydroxyzine is an antihistamine with significant sedative properties that could precipitate respiratory depression in an asthmatic patient 3
• The British Thoracic Society explicitly states that sedatives should never be used in asthma patients due to risk of respiratory compromise 1

Recommended Treatment Approach: Optimize Sertraline

• Sertraline is highly effective for panic disorder at doses of 50-175 mg daily, with most patients requiring 100-200 mg for optimal response 4
• Your patient is currently on 100 mg sertraline, which is at the lower end of the therapeutic range for panic disorder 4
• Increase sertraline by 25-50 mg every 1-2 weeks as tolerated, targeting 150-200 mg daily 1
• Sertraline has demonstrated significant efficacy in reducing panic attack frequency by approximately 79-80% in clinical trials 5

Nortriptyline Assessment Plan

• Your plan to have the PCP reassess nortriptyline appropriateness is reasonable but not urgent 1
• Nortriptyline at 10 mg daily is a very low dose (therapeutic range for depression/pain is typically 40-150 mg daily) 1
• At this low dose for cyclic vomiting prophylaxis, nortriptyline is unlikely to interfere with sertraline escalation 6
• Monitor for serotonin syndrome when combining serotonergic agents, though risk is low at these doses 1
• Key symptoms to monitor: confusion, agitation, tremors, tachycardia, diaphoresis, which typically appear within 24-48 hours of dose changes 1

Sertraline Dose Escalation Protocol

• Start by increasing to 125 mg daily for 1-2 weeks 1
• If tolerated but panic attacks persist, increase to 150 mg daily 4
• Maximum dose for panic disorder is typically 200 mg daily 1
• Use smallest available increments (25 mg) to minimize activation/agitation side effects 1
• Common side effects include nausea, insomnia, tremor, and sexual dysfunction 1

Alternative Anxiolytic Options (If Needed)

• If breakthrough panic attacks occur during sertraline titration, consider short-term benzodiazepines as-needed (e.g., lorazepam 0.5-1 mg) rather than hydroxyzine 5
• Benzodiazepines do not impair sertraline efficacy and are safer than sedating antihistamines in asthma patients 5
• Prior benzodiazepine use does not reduce sertraline response rates (67% vs 61% response regardless of prior BDZ exposure) 5

Monitoring Parameters

• Reassess panic attack frequency weekly during dose titration 4
• Monitor for behavioral activation, particularly in the first 2-4 weeks after dose increases 1
• Check blood pressure if increasing above 150 mg, as sertraline can occasionally cause hypertension 1
• Ensure asthma remains stable; any respiratory symptoms require immediate evaluation 1, 2

Timeline for Response

• Initial improvement in panic symptoms typically occurs within 2-4 weeks 4
• Full therapeutic effect may take 6-8 weeks at target dose 1
• If no response after 8 weeks at 200 mg, consider switching to an SNRI (venlafaxine 150-225 mg daily) 1