Pharmacological approaches to the management of panic disorder in older patients: a systematic review

ABSTRACT

Introduction

Recommendations for treating panic disorder (PD) in older patients are scarce. The authors have systematically reviewed whether several recommended medications are superior to others and their optimal doses in this age group.

Methods

A database search of studies involving patients with PD with/without agoraphobia aged ≥ 60 years was carried out using PubMed, PsycINFO, Embase, and Clinical Trials.gov, from their inception dates to 1 March 2023. Only four (published from 2002 to 2010) of the 1292 records screened were included. A risk of bias assessment was provided. This systematic review was performed using The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

Results

Two studies were randomized clinical trials, whereas two were open-label, including paroxetine, citalopram, escitalopram, and sertraline; three studies reported short-term evaluations, whereas one study included a 26-week follow-up. Medications provided benefits, with good tolerability. Preliminary results suggested greater benefits of paroxetine in reducing panic attacks vs. cognitive – behavioral therapy, and an earlier decrease in PAs with escitalopram vs. citalopram. Risk of bias was considerable.

Conclusions

The pharmacological management of PD in older patients has received no attention. Findings are scant, dated, and affected by methodological flaws; thus, they do not provide significant advances.

KEYWORDS:

• Panic disorder
• older
• pharmacotherapy
• selective serotonin reuptake inhibitors
• SSRIs
• antidepressants
• personalized

Article highlights

• Exhaustive guidelines for pharmacological treatment of panic disorder (PD) in the older are lacking, despite some age- and onset-related features of panic disorder (PD) suggesting older patients may need tailored guidelines.

• The present comprehensive systematic review identified only two randomized and two open-label clinical trials specifically involving older patients. All studies included selective serotonin reuptake inhibitors.

• The heterogeneity of the design and outcome assessment, the considerable risk of bias, and the overall low quality of the few available data limited the possibility of gathering useful indications for clinical practice in older patients.

• The questions of whether some recommended medications may be superior to others, as well as the optimal doses to maximize their clinical effectiveness and tolerability in this age group remain unanswered.

• Additional research is warranted.

• Gathering large arrays of information from highly inclusive, prospective, long-term, multicentre studies from ‘real-life’ settings and using recent technological advances might contribute to the faster clinical application of personalized pharmacotherapy of older patients with PD.

Declaration of interest

D Caldirola, S Dacco and G Perna are scientific consultants for Medibio Ltd. G Perna is also a scientific consultant for Menarini, Lundbeck and Pfizer Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.