Which drugs are used in the treatment of panic disorder?

Updated: Mar 21, 2018
  • Author: Mohammed A Memon, MD; Chief Editor: Randon S Welton, MD  more...
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First-line pharmacologic therapies for panic disorder include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs). [55] These 3 classes of agents are preferred over benzodiazepines as monotherapies for patients with co-occurring depression or substance use disorders.

The FDA issued a Drug Safety Communication in August 2011 stating that the SSRI, citalopram (Celexa), should not be used at doses greater than 40 mg per day, owing to the potential for dangerous abnormalities in cardiac electrical activity. [57] Citalopram 20 mg per day is the maximum recommended dose in patients with hepatic impairment, who are older than 60 years, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine (Tagamet) or another CYP 2C19 inhibitor. Such individuals can have higher blood levels of citalopram, leading to an increased risk of prolonged QT interval and torsade de pointes. [57]

Additional warnings as of March 2012 discourage the use of citalopram at any dose in patients with certain conditions (congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute myocardial infarction, uncompensated heart failure) due to potentially dangerous prolongation of the QT interval. [57]

For patients requiring rapid symptom control, benzodiazepines can be used as adjuncts with antidepressant agents to treat residual anxiety symptoms, and they may be preferred (as monotherapies or in combination with antidepressants). [55] Clinicians must carefully assess the benefit of more rapid response against the potential complications of benzodiazepine therapy.

The American Psychiatric Association (APA) recommends avoiding TCAs for patients with panic disorder who also have acute narrow-angle glaucoma or clinically significant prostatic hypertrophy. [55] TCAs may increase the risk of falls and fractures, particularly in elderly patients. In addition, owing to the potential for significant or fatal arrhythmia in patients with preexisting cardiac conduction abnormalities, it is important to obtain an electrocardiogram (ECG) in these individuals before starting TCA treatment. Use TCAs with caution in suicidal patients as overdoses with these drugs can cause cardiac toxicity and death. [55]

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