Panic Disorder Medication
- Author: Mohammed A Memon, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK) more...
Intermediate-Acting Benzodiazepines
Class Summary
By binding to specific receptor sites, intermediate-acting benzodiazepines appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. These agents are effective on standing-dose and prn schedules.
Lorazepam (Ativan)
Lorazepam is a sedative hypnotic with a short onset of effects and a relatively intermediate half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, lorazepam may depress all levels of the CNS, including the limbic and reticular formations.
Clonazepam (Klonopin)
Clonazepam facilitates inhibitory GABA neurotransmission and other inhibitory transmitters. It has a relatively longer half-life (approx 36 h).
Alprazolam (Xanax, Xanax XR)
Alprazolam is for the management of anxiety attacks. It binds to receptors at several sites within the CNS, including the limbic system and the reticular formations. Its effects may be mediated through the GABA receptor system. Alprazolam has been reviewed in the literature, although its use is currently discouraged because of its higher potential to elicit dependency.
Diazepam (Valium, Diastat, Diazepam Intensol)
Diazepam depresses all levels of the CNS (eg, the limbic and reticular formations), possibly by increasing the activity of GABA.
Serotonin Reuptake Inhibitor/Antagonist
Class Summary
The mechanism of antidepressant action of this class of drugs is not fully understood in humans. These agents are not MAOIs and, unlike amphetamine-type drugs, do not stimulate the CNS.
Trazodone
Trazodone is useful in the treatment of panic disorder and agoraphobia with panic attacks. It is an antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. It also has a negligible affinity for cholinergic and histaminergic receptors.
In animals, this drug selectively inhibits serotonin uptake by brain synaptosomes and potentiates the behavioral changes induced by the serotonin precursor, 5-hydroxytryptophan.
Selective Serotonin Reuptake Inhibitors
Class Summary
SSRIs are first-line agents for long-term management of anxiety disorders. Control is gradually achieved over a 2- to 4-wk course, depending on required dosage increases.
All commonly used SSRIs appear to have a role in the treatment of panic disorder. Fluoxetine is covered herein, because it has a very long half-life. This makes it well suited for patients who have difficulty remembering to take all of their medications each day. The longer half-life also minimizes the risk and severity of SSRI withdrawal that can occur when patients exhaust or abruptly discontinue their SSRI.
Fluoxetine (Prozac)
Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on reuptake of norepinephrine or dopamine.
Paroxetine (Paxil, Paxil CR)
This is an alternative sedating SSRI. Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has weak effect on norepinephrine and dopamine neuronal reuptake.
Sertraline (Zoloft)
This agent selectively inhibits presynaptic serotonin reuptake. It also has a weak inhibitory effect on norepinephrine and dopamine neuronal reuptake.
Fluvoxamine (Luvox, Luvox CR)
Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and therefore has fewer adverse effects than do tricyclic antidepressants.
Citalopram (Celexa)
Citalopram enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. SSRIs are the antidepressants of choice due to minimal anticholinergic effects.
Escitalopram (Lexapro)
Escitalopram is a selective serotonin reuptake inhibitor and S-enantiomer of citalopram. Its mechanism of action is thought to be potentiation of serotonergic activity in the CNS resulting from the inhibition of CNS neuronal reuptake of serotonin.
Tricyclic Antidepressants
Class Summary
TCAs have the advantages of once-daily dosing, low risk of dependence, and no dietary restrictions. However, they are discontinued in 35% of cases because of adverse effects, such as blurred vision, dry mouth, dizziness, weight gain, gastrointestinal disturbance, agitation, insomnia, headache, and decreased libido or ability to orgasm. TCAs must be started in low doses to avoid amphetamine like stimulation and can require up to 8-12 weeks for treatment response.
Imipramine (Tofranil, Tofranil-PM)
Imipramine inhibits the reuptake of norepinephrine and serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neurons.
Desipramine (Norpramin)
Desipramine may increase the synaptic concentration of norepinephrine in the CNS by inhibiting the reuptake by the presynaptic neuronal membrane. It may have effects in the desensitization of adenyl cyclase, down-regulation of beta-adrenergic receptors, and down-regulation of serotonin receptors.
Clomipramine (Anafranil)
This agent affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite, desmethylclomipramine.
Monoamine Oxidase Inhibitors
Class Summary
These are effective in patients with social phobia. Advantages of MAOIs are low risk of dependence and less anticholinergic effect than TCAs. Disadvantages are the higher number of adverse effects, including sexual difficulty, hypotension, weight gain, dry mouth, tachycardia, insomnia, drowsiness, headache, weakness, and constipation.
Phenelzine (Nardil)
Nardil is the MAOI that is most commonly used for panic disorder. It has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of panic disorder. The drug is usually reserved for patients who do not tolerate or respond to traditional cyclic or second-generation antidepressants.
Tranylcypromine (Parnate)
This drug is also effective against panic disorder. It binds irreversibly to MAO, thereby reducing monoamine breakdown and enhancing synaptic availability.
Serotonin Norepinephrine Reuptake Inhibitors
Class Summary
The dual serotonin-norepinephrine reuptake inhibitor antidepressant (SNRI), venlafaxine (Effexor, Effexor XR), is indicated for panic disorders.
Venlafaxine (Effexor, Effexor XR)
Venlafaxine is a serotonin/norepinephrine reuptake inhibitor. It may treat depression by inhibiting neuronal serotonin and norepinephrine reuptake. In addition, it causes beta-receptor down-regulation.
Alpha-2 Antagonists
Class Summary
The alpha-2 adrenergic antagonists increase synaptic norepinephrine and serotonin, while also blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin.
Mirtazapine (Remeron, Remeron SolTab)
Mirtazapine has a much more sedating effect, generally reducing its potential to aggravate initial anxiety. Remeron may cause residual morning sedation that often improves with continued therapy and may cause an increase in appetite or weight gain.
Sedating antidepressants, such as Remeron are usually prescribed for use only at night before bed to help improve sleep, but they should include a warning for the patient not to operate a motor vehicle or machinery if he or she is feeling sedated or directly after the dose.
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