Antianxiety Agents

I. Benzodiazepines A. Indications. Benzodiazepines are used for the treatment of anxiety disorders, insomnia, seizure disorders, and detoxification from alcohol. They are also effective adjunctive agents for agitated psychotic or depressive states. 1. All benzodiazepines induce tolerance and are addictive. Short courses of treatment should be used whenever possible. 2. The primary indications for long term treatment are chronic anxiety disorders such as generalized anxiety disorder and panic disorder. 3. When benzodiazepines are discontinued, the drug should be tapered slowly. Long acting agents such as clonazepam and diazepam are preferable for long term treatment because they cause less withdrawal and require less frequent dosing. 4. The 3-hydroxy-benzodiazepines (lorazepam, alprazolam, oxazepam) have no active metabolites and are the agents of choice in patients with impaired liver function. 5. Acute agitation usually is treated with lorazepam (Ativan), 2 mg IM because it is well tolerated and effective in most patients. B. Side Effects 1. Sedation is the most common and universal side effect, and patients should be cautioned about driving after taking benzodiazepines. Tolerance to sedative effects often occurs during the first few weeks of treatment. 2. Cognitive Dysfunction. Anterograde amnesia is common after benzodiazepine use, especially with high potency agents (alprazolam) or short acting agents (triazolam). 3. Miscellaneous Side Effects a. Benzodiazepines may produce ataxia, slurred speech, and dizziness. b. Respiratory depression can occur at high doses, especially in combination with alcohol or respiratory disorders, such as chronic obstructive pulmonary disease. c. Benzodiazepines are contraindicated in pregnancy or lactation. Antianxiety Agents
Name Trade Name Dose (mg) Dose Equivalence 0.5 Half-Life of Metabolites (hours) 6-20

Alprazolam

Xanax

0.25-2 tid/qid 25-50 tid/qid 0.25-2 bid/tid

Chlordiazepoxide Clonazepam

Librium

10

30-100

Klonopin

0.25

18-50

Name

Trade Name

Dose (mg)

Dose Equivalence 7.5 5 20 1 15

Half-Life of Metabolites (hours) 30-100 30-100 30-100 10-20 8-12

Clorazepate Diazepam Halazepam Lorazepam Oxazepam

Tranxene Valium Paxipam Ativan Serax

7.5 -30 bid 2-15 bid/tid 20-80 bid 0.52 tid/qid 15-30 tid/qid 5-20 bid/tid

Prazepam

Centrax

10

30-100

II. Buspirone A. Buspirone is a nonbenzodiazepine anxiolytic agent of the azaperone class. B. Indications 1. Buspirone (BuSpar) is indicated for anxiety disorders such as generalized anxiety disorder; however it is not effective for panic disorder. 2. It may also be an effective adjunctive agent in the treatment resistant depression. It may be added in a dosage of 15-60 mg/day if a patient has had a suboptimal response to a 3-6 week trial of an antidepressant. C. Dosage 1. The starting dose is 5 mg two to three times a day. Gradually increase to a maximum dosage of 60 mg per day over several weeks. 2. Many patients respond to a total dose of 30 - 40 mg per day in two to three divided doses. 3. At least two weeks are required before clinical improvement occurs. It is common to see the first signs of improvement after 3-6 weeks. D. Side Effects 1. Buspirone is generally well tolerated; the most common side effects are nausea, headaches, dizziness, and insomnia. 2. Buspirone is not addicting and has no withdrawal syndrome or tolerance, and it does not produce sedation or potentiate the effects of alcohol.