Antianxiety Agents 95

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 Dose (mg) Dose Half-Life of

Name Equival- Metabolites
ence (hours)

Alprazolam Xanax 0.25-2 0.5 6-20

tid/qid

Chlordiazep- Librium 25-50 10 30-100

oxide tid/qid

Clonazepam Klonopin 0.25-2 0.25 18-50

bid/tid
96 Antianxiety Agents

Name Trade Dose (mg) Dose Half-Life of

Name Equival- Metabolites
ence (hours)

Clorazepate Tranxene 7.5 -30 bid 7.5 30-100

Diazepam Valium 2-15 bid/tid 5 30-100

Halazepam Paxipam 20-80 bid 20 30-100

Lorazepam Ativan 0.5–2 tid/qid 1 10-20

Oxazepam Serax 15-30 15 8-12

tid/qid

Prazepam Centrax 5-20 bid/tid 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.