A 32-year-old man comes to the office due to recurrent episodes of chest pain, dizziness, and numbness. The patient says, "Suddenly, my heart starts pounding and I have trouble breathing. Then my whole body shakes, I start to sweat, and I feel like I'm going to faint. Many times I also notice numbness and tingling in both arms. It only lasts for a few minutes, but it feels like hours." The episodes occur 3 or 4 times a week. He is very worried that similar episodes will occur at work and that he will pass out. The patient has a history of occasional insomnia and hypertension treated with enalapril. His mood is good, and he enjoys his work and spending time with family and friends. The patient both smokes marijuana and drinks 2 or 3 glasses of wine daily. Family history is significant for hypertension, coronary artery disease, and seizure disorder. Physical examination is unremarkable, and laboratory results and ECG are normal. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 32-year-old man comes to the office due to recurrent episodes of chest pain, dizziness, and numbness.  The patient says, "Suddenly, my heart starts pounding and I have trouble breathing.  Then my whole body shakes, I start to sweat, and I feel like I'm going to faint.  Many times I also notice numbness and tingling in both arms.  It only lasts for a few minutes, but it feels like hours."  The episodes occur 3 or 4 times a week.  He is very worried that similar episodes will occur at work and that he will pass out.  The patient has a history of occasional insomnia and hypertension treated with enalapril.  His mood is good, and he enjoys his work and spending time with family and friends.  The patient both smokes marijuana and drinks 2 or 3 glasses of wine daily.  Family history is significant for hypertension, coronary artery disease, and seizure disorder.  Physical examination is unremarkable, and laboratory results and ECG are normal.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d7de_9c48_bc81_27644ae7c4a3_MD0003_00 Recurrent, unexpected episodes of chest pain, shortness of breath, trembling, sweating, and dizziness lasting several minutes are consistent with panic disorder. This patient's paresthesia (eg, numbness, tingling) is also characteristic. First-line treatment options for panic disorder include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and/or cognitive-behavioral therapy. Benzodiazepines (eg, alprazolam, diazepam) are also effective. However, due to the risks of abuse and addiction, they are typically reserved for short-term use in acutely symptomatic and functionally impaired patients who require rapid relief. They may also be used in patients who do not respond to or cannot tolerate antidepressants. Because benzodiazepines are best avoided in patients with a history of or suspicion for substance abuse, they should not be used as first-line treatment in this patient who smokes marijuana daily and exceeds the recommended limit of 14 alcoholic drinks per week (Choices A and C). (Choice B) Buspirone is an antianxiety agent but is not effective for panic disorder. It has a role in the treatment of generalized anxiety disorder. (Choice D) Beta blockers as monotherapy are not effective in panic disorder but have been used to treat performance anxiety. Educational objective: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line pharmacotherapy for panic disorder. Benzodiazepines are reserved for patients who require immediate relief and should be avoided in those with substance abuse. References: Evidence-based pharmacotherapy of panic disorder: an update. (http://www.ncbi.nlm.nih.gov/pubmed/21733234) Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736)

A 32-Year-Old Man Comes to the Office Due to Recurrent