NICE guidance regarding pharmacological therapy for panic disorder

Points to consider when pharmacological management of panic disorder is employed include (1):

• General principles
  • benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder
    
    
  • sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder
    
    
  • antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder. The two classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs)
    
    
    • all people who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drugs
      
      
    • people started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the person's needs should be made available
      
      
    • unless otherwise indicated, an SSRI licensed for panic disorder should be offered
      
      
    • if an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered
      
      
    • When prescribing an antidepressant, the healthcare professional should consider the following
      • side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.
      • in some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed
      • long-term treatment may be necessary for some people and should be offered if needed
      • if the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered
        
        
    • if there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy should be offered
      
      
    • people should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms
      
      
    • stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time
      
      
    • all people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly
      
      
    • healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances
      
      
    • healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms
      
      
    • if discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms

For more detailed information then consult the full guideline (1).

Reference:

1. NICE (July 2019).Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care