A 28-year-old man comes to the office due to frequent anxiety attacks over the past several months. He says, "At first I shook it off because the attacks subside rapidly, but now I'm worried it will happen again while I'm at work or driving. All of a sudden I feel faint, start to shake and sweat, and my heart starts racing. I thought my heart was going to jump out of my chest." The patient has no history of cardiac disease and takes no medication. He has a history of alcohol use disorder in his early twenties and smokes marijuana occasionally. The patient appears calm and his vital signs are within normal limits. Physical examination and ECG show no abnormalities. Which of the following is the most appropriate pharmacotherapy?

Question

A 28-year-old man comes to the office due to frequent anxiety attacks over the past several months.  He says, "At first I shook it off because the attacks subside rapidly, but now I'm worried it will happen again while I'm at work or driving.  All of a sudden I feel faint, start to shake and sweat, and my heart starts racing.  I thought my heart was going to jump out of my chest."  The patient has no history of cardiac disease and takes no medication.  He has a history of alcohol use disorder in his early twenties and smokes marijuana occasionally.  The patient appears calm and his vital signs are within normal limits.  Physical examination and ECG show no abnormalities.  Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec160b_3634_e445_9249_13b4b9e56eeb_MD0001_00 Panic disorder is a chronic anxiety disorder characterized by recurrent, unexpected panic attacks, anticipatory anxiety about future attacks, and phobic avoidance. Both antidepressants and benzodiazepines are effective for panic disorder. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors are preferred first-line therapy due to their relatively benign side effect profile compared to tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs). Benzodiazepines are also effective and have more rapid onset of action. They are useful in severely symptomatic and functionally impaired patients who require rapid relief. However, benzodiazepines carry risks for abuse and result in physiological dependence and withdrawal if stopped abruptly. Benzodiazepines should be avoided in patients with a history of substance abuse. An SSRI would be the preferred choice in this patient who is not acutely symptomatic and has a history of alcohol abuse (Choice B). (Choices A and C) There is no evidence to support the use of antipsychotics or beta blockers as monotherapy for panic disorder. (Choice D) MAOIs are effective in panic disorder but are not used as first-line therapy due to required dietary restrictions and avoidance of certain medications and to the risk of severe adverse effects (hypertensive crisis, serotonin syndrome). (Choice F) Although effective, tricyclic antidepressants have a greater side effect burden (eg, anticholinergic effects, orthostatic hypotension, cardiac conduction delays, danger in overdose) and have largely been replaced by SSRIs. Educational objective: Pharmacotherapy of panic disorder includes selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. SSRIs are often preferred to benzodiazepines due to the lack of physiological dependence and abuse potential. __________ References: Evidence-based pharmacotherapy of panic disorder: an update. (http://www.ncbi.nlm.nih.gov/pubmed/21733234)

A 28-Year-Old Man Comes to the Office Due to Frequent