Panic disorder

Lothian: Antidepressants - Swapping and Stopping

First line treatment is non-pharmacological measures. Treatment options for anxiety disorders include psychological, and guided self-help approaches as first line. Choice of treatment in individual cases will usually be determined by patient preference, and the severity of the condition.

Initially 25mg daily for 1 week, increased to 50mg daily. If partial response then dose can be increased in 50mg increments at intervals of at least 1 week to 200mg daily maximum.

Prescribing Notes:

There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
There may be an increase in impulsive thoughts when an SSRI is started especially during the first week of treatment. Special caution should be exercised in those patients under 25 years of age.
Co-prescribing of a benzodiazepine may be useful for 2-4 weeks during the initiation of an SSRI.
Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
SSRIs are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting. Consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin.
SSRIs should be used with caution in patients over 80 years due to the risk of gastro-intestinal bleeding.
Patients who have had a recent cardiovascular event should be prescribed sertraline, it has less negative effects on the QT interval.
Symptoms frequently deteriorate before they improve in panic disorder and this initial exacerbation may be minimised by commencing treatment.
6-12 months of treatment is generally indicated prior to gradual discontinuation of treatment.
General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.

History Notes

09/04/2024

Addition of link to general notes on prescribing in pregnancy, ERWG May 24.

27/10/2022

East Region Formulary content agreed.

Diagnosis and treatment should be initiated by a specialist.

Dose as per specialist and BNFc.

Prescribing Notes:

Some patients manage without drug treatment. For many, optimal treatment will be a combination of psychological therapy and drug treatment.
There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
There may be an increase in impulsive thoughts when an SSRI is started especially during the first week of treatment. Special caution should be exercised in those patients under 25 years of age.
Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
SSRIs are associated with an increased risk of bleeding, especially in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting.
Patients who have had a recent cardiovascular event should be prescribed sertraline, it has less negative effects on the QT interval.
Symptoms frequently deteriorate before they improve in panic disorder and this initial exacerbation may be minimised by commencing treatment.
6-12 months of treatment is generally indicated prior to gradual discontinuation of treatment.
Suicidal behaviour has been linked with the use of antidepressants, particularly in children and young people. Children and young people should be monitored for suicidal behaviour and risk of self-harm, particularly at the beginning of treatment or if the dose is changed.

History Notes

05/03/2025

Sertraline formulation update, ERFC Feb 25.

15/01/2024

East Region Formulary content agreed.