Trip Answers

Question answered:22/04/08

In answering this question, we do not know the medications the patient in question is taking to control their asthma. Two resources dealing with the management of panic disorder in general, as opposed to in patients with asthma, recommend SSRIs be tried as a first-line therapy (after cognitive behavioural therapy has been tried).

 

We found very little information on the use of calcium channel blockers to treat panic symptoms or panic disorders in asthma patients or in general. An e-Medicine article on panic disorder states in the section on treatment:

 

“…Other antidepressants that have an effect on the serotonergic system have been used, especially when SSRIs have been ineffective or poorly tolerated. In the past, and sometimes even now, these have been the tricyclics and the monoamine oxidase inhibitors (MAOIs). More recently, venlafaxine (Effexor) and mirtazapine (Remeron) have been used. Beta-blockers, clonidine, calcium channel blockers, antipsychotics, buspirone, and anticonvulsants such as divalproex (Depakote) and gabapentin (Neurontin) have also been used as adjunctive agents in patients with refractory panic disorder, although these uses have not been approved by the US Food and Drug Administration.” [1]

 

The Medline database contains just one reference to the use of calcium channel blockers in treating anxiety disorders. This is a review article and dates from 1996. The abstract of this article reads:

 

“The role of calcium in the etiology of anxiety has been proposed for several decades. Calcium channel blockers profoundly influence calcium metabolism and the transport of calcium. Even though the evidence for the role of calcium remains weak, drugs affecting calcium might be useful in the treatment of anxiety disorders. One of these compounds, verapamil, has been used to treat mood disorders. Calcium channel blockers have also been tried in other indications such as premenstrual syndrome, irritable bowel syndrome, schizophrenia, tardive dyskinesia, and Tourette's syndrome. However, the number of articles on the use of calcium channel blockers in the treatment of anxiety disorders is low. Three reports (two open, one double-blind) described some success in the treatment of panic disorder with verapamil, diltiazem, or nimodipine and one open-label study described unsuccessful treatment of anxiety and phobia with nifedipine in patients with various anxiety disorders. Further double-blind placebo-controlled studies of calcium channel blockers in the treatment of anxiety disorders are warranted to determine a possible role of these compounds in the armamentarium of antianxiety drugs.[2]

 

Concerning the treatment of panic disorders, we found no guidelines specifically addressing the management of panic attacks in patients with asthma.

 

However, the Best in Mental Health clinical Q & A Service answered a question on the effectiveness of CBT in treating patients with panic disorder and asthma in 2007. It concludes:

 

“The BEST in MH search strategy did not identify any trials of CBT in patients with both panic disorder and asthma. A recent well conducted Cochrane review identified three RCTs of interventions including cognitive elements in adults with asthma only. The reviewers concluded that there is insufficient evidence to determine the effectiveness of psychological interventions for adult asthma." [3]

 

The 2004 NICE guideline makes recommendations on the management of panic disorders in general:

 

“Panic disorder

 

• Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder.

 

• Any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are:

 

− psychological therapy (cognitive behavioural therapy [CBT])

 

− pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipramine or clomipraminea may be considered)

 

− self-help (bibliotherapy – the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour – based on CBT principles).” [4]

 

A second source, the Patient Plus website contains an article on the management of panic disorder and this discusses recommended (both pharmacological and non-pharmacological therapies) as well as non-recommended therapies. The full text of this article can be read by following the link given in the references section. [5]

 

References
1. Daniels C. Panic disorder. e-Medicine. April 2006. (http://www.emedicine.com/med/topic1725.htm#section~Treatment)
2. Balon R and Ramesh C. Calcium channel blockers for anxiety disorders? Ann Clin Psychiatry. 1996 Dec;8(4):215-20. (
3. Best in Mental Health. Question: In adults with both panic disorder and asthma, how effective is cognitive behaviour therapy compared with other active treatments in reducing panic and improving asthma control? March 2007. (http://www.bestinmh.org.uk/answers/pdf/BestInMHAnswer216.pdf)
4. NICE. Anxiety : management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. 2004. (http://www.nice.org.uk/nicemedia/pdf/CG022NICEguidelineamended.pdf)
5. PatientPlus. Panic disorder and its management. August 2007. (http://www.patient.co.uk/showdoc/40026084/)

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