What is beneficial for short-term management of panic attacks in a patient taking Clonazepam (1mg twice daily), Imovan (Zopiclone) 7.5mg, Lamotrigine 150mg nocte, and Mirtazapine 45mg nocte?

From the Guidelines

For short-term management of panic attacks in a patient already taking clonazepam, Imovane, lamotrigine, and mirtazapine, I would recommend a short course of an SSRI or an anxiolytic, such as alprazolam 0.25-0.5mg as needed for acute panic episodes, limited to 2-4 weeks use, as suggested by the American Society of Clinical Oncology guideline adaptation 1. When considering the patient's current medication regimen, including clonazepam 1mg BD, Imovane 7.5mg, lamotrigine 150mg nocte, and mirtazapine 45mg nocte, it is essential to choose an intervention with a short-term duration and monitor regularly for adherence, side effects, and adverse events 1. Some key points to consider when prescribing anxiolytics for this patient include:

• Physician-prescribed medications should be informed by side effect profiles, interactions, response, patient age, and preference 1
• The patient should be instructed to use the medication only when experiencing significant panic symptoms, with a maximum of 2-3 doses per day and at least 4 hours between doses
• Cognitive behavioral techniques, such as controlled breathing exercises and grounding techniques, should be implemented alongside medication to reduce dependence on medication and provide sustainable coping strategies for panic management
• Regular monitoring is crucial to ensure the patient's safety and adjust the treatment plan as needed, considering the potential risks of excessive sedation and respiratory depression when combining anxiolytics with other central nervous system depressants 1

From the FDA Drug Label

Clonazepam is highly metabolized, with less than 2% unchanged clonazepam being excreted in the urine. The effectiveness of clonazepam in the treatment of panic disorder was demonstrated in two double-blind, placebo-controlled studies of adult outpatients who had a primary diagnosis of panic disorder (DSM-IIIR) with or without agoraphobia In these studies, clonazepam was shown to be significantly more effective than placebo in treating panic disorder on change from baseline in panic attack frequency, the Clinician’s Global Impression Severity of Illness Score and the Clinician’s Global Impression Improvement Score. A significant difference from placebo was observed consistently only for the 1 mg/day group The difference between the 1 mg dose group and placebo in reduction from baseline in the number of full panic attacks was approximately 1 panic attack per week.

The patient is already taking clonazepam 1mg BD, which has been shown to be effective in treating panic disorder.

• For short-term use, it may be beneficial to continue or increase the current dose of clonazepam under medical supervision, as the patient is already taking a dose that has been shown to be effective in clinical trials 2.
• However, caution should be exercised when administering clonazepam, especially in patients with liver disease, as it undergoes hepatic metabolism.
• It is also important to monitor the patient's response to the current medication regimen and adjust as needed to minimize the risk of adverse effects.

From the Research

Short-term Management of Panic Attacks

For a patient already taking clonazepam 1mg BD, imovan 7.5mg, lamotrigine 150mg nocte, and mirtazapine 45mg nocte, the following options may be beneficial for short-term use:

• Benzodiazepines, such as alprazolam or diazepam, have been shown to be effective in the short-term management of panic disorder 3, 4
• Clonazepam, which the patient is already taking, has been found to be effective in reducing panic attacks, with a minimum effective dosage of 1.0 mg daily 5
• Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, may also be effective in the short-term management of panic disorder, although they may take longer to start working than benzodiazepines 6, 4

Key Considerations

• The patient is already taking a benzodiazepine (clonazepam), so adding another benzodiazepine may increase the risk of adverse effects such as sedation and dependence 3
• The patient's current medication regimen should be taken into account when considering adding a new medication, to minimize potential interactions and adverse effects
• The effectiveness and tolerability of different medications can vary between individuals, so close monitoring and adjustment of the treatment plan may be necessary 4, 5

Medication Options

• Alprazolam: a benzodiazepine that has been shown to be effective in reducing panic attacks, with a rapid onset of action 3, 4
• Diazepam: a benzodiazepine that has been found to be effective in reducing panic attacks, with a longer half-life than alprazolam 3, 4
• Paroxetine: an SSRI that has been shown to be effective in reducing panic attacks, although it may take longer to start working than benzodiazepines 6, 4