Management of Anxiety and Panic Attacks in Multiple Sclerosis Patients

First-Line Treatment: SSRIs

The American College of Neurology recommends sertraline as the first-line pharmacological treatment for anxiety and panic attacks in MS patients, starting at 25 mg/day, with duloxetine as an alternative when comorbid pain is present 1
Sertraline dosing should start at 25 mg/day for the first week, then increase to 50 mg/day, with a target dose of 50-200 mg/day in a single daily dose, and a maximum dose of 200 mg/day 1
Statistically significant improvement with sertraline can be expected within 2 weeks, with clinically significant improvement by week 6, and maximal improvement by week 12 or later 1

Duloxetine is the preferred SNRI, particularly beneficial when MS patients have comorbid pain conditions, with an initial dose of 30 mg daily for one week, then increased to 60 mg/day, and a maximum dose of 120 mg/day 1
Venlafaxine extended-release is an alternative SNRI, effective but requires careful blood pressure monitoring due to risk of sustained hypertension 1

Common side effects to monitor include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness, with most adverse effects emerging within the first few weeks of treatment 1
Fatigue/somnolence, particularly with SNRIs, should be monitored, as well as blood pressure increases with venlafaxine 1, 2

Cognitive impairment is common in MS and may be worsened by certain medications, so sedating antihistamines and anticholinergic medications that can cause cognitive decline should be avoided 3
The overlap between anxiety, depression, and fatigue in MS is substantial, with a prevalence of anxiety disorders of 22-54%, and comorbid major depressive disorder influencing medication choice 3