Which drugs other than SSRIs are used in the management of panic disorder?

Updated: Mar 21, 2018
  • Author: Mohammed A Memon, MD; Chief Editor: Randon S Welton, MD  more...
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Sertraline (Zoloft) represents a similar SSRI option with a slightly different pharmacodynamic profile, including sigma-receptor effects, although it has some P450 3A4 interactions.

Paroxetine (Paxil), mirtazapine, and TCAs are usually prescribed for use before bedtime to help improve sleep. Caution patients to avoid operating a motor vehicle or machinery directly after the dose or if they are feeling sedated.

Paroxetine is also available in a controlled release preparation (Paxil CR), which may improve tolerability, but it still inhibits P450 2D6. Paroxetine is a category D drug during pregnancy (ie, human studies have shown a risk to the fetus, but the drug’s benefits may outweigh the risk in pregnant women). Use of this medication requires patient counseling as well as documentation of the potential risks in women of reproductive age.

Mirtazapine (Remeron), a noradrenergic and specific serotonergic antidepressant (NaSSA), has a much more sedating effect, generally reducing its potential to aggravate initial anxiety. [35] Mirtazapine acts distinctly as an alpha-2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while it also blocks some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin. Note that mirtazapine may cause residual morning sedation that often improves with continued therapy, and it may also cause an increase in appetite or weight gain.

Most patients are started on long-term (e.g., 6 mo) therapy with SSRIs, TCAs, or MAOIs only after consultation with their primary physician or psychiatrist.

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