Maintenance pharmacotherapy for panic disorder in adults and young people
For the acute management of a panic attack, see here.
Treat panic disorder with psychosocial interventions. If psychosocial interventions are not available, not effective or not preferred, consider pharmacotherapy.
If an antidepressant is indicated for maintenance treatment of panic disorder, initial choice should be informed by:
- the drug’s adverse effect profile, potential for drug interactions and safety in overdose
- the patient’s comorbidities
- the patient’s age:
- older people are more likely to have multiple comorbidities or be more sensitive to antidepressant adverse effects (eg hyponatraemia with selective serotonin reuptake inhibitors [SSRIs])
- young people more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with SSRIs. Despite this, SSRIs remain a first-line option when antidepressant therapy is indicated; paroxetine, however, should be avoided because it has been associated with an increased risk of suicidal thoughts and behaviours and other serious adverse events
- the patient’s response to previous treatments and family history of response to treatments
- tolerability when stopping treatment
- whether the patient is planning pregnancy, or is pregnant or breastfeeding (also see Considerations in managing anxiety disorders during the perinatal period).
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) are first-line drugs for panic disorder. Compared to other indications, lower initial doses are used because patients with panic disorder can be extremely sensitive to the activating effects of SSRIs.
The serotonin noradrenaline reuptake inhibitors (SNRIs) (desvenlafaxine, duloxetine, venlafaxine) have less evidence than SSRIs in panic disorder, but are an option in patients who have a poor response to, or cannot tolerate, SSRIs.
If an SSRI or SNRI is considered appropriate for panic disorder, individualise the choice of drug (see above). Lower doses may be needed in older people; consult a source of drug information. Use:
1 citalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder (adult) citalopram citalopram citalopram
OR
1 escitalopram 5 mg orally, in the morning, increasing to 10 mg in the morning after 1 week. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder (adult) escitalopram escitalopram escitalopram
OR
1 fluoxetine 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder (adult) fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 25 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder (adult) fluvoxamine fluvoxamine fluvoxamine
OR
1 paroxetine 10 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder paroxetine paroxetine paroxetine
OR
1 sertraline 25 mg orally, in the morning, increasing to 50 mg in the morning after 1 week. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder (adult) sertraline sertraline sertraline
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 30 mg orally, daily. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 120 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing panic disorder duloxetine duloxetine duloxetine
OR
2 venlafaxine modified-release 37.5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 37.5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing. panic disorder venlafaxine venlafaxine venlafaxine