From the Guidelines
For a patient with new onset panic attacks currently on sertraline 25 mg and Ativan 0.5 mg PRN, a good alternative second therapy instead of Ativan would be buspirone, as it is non-addictive and doesn't cause sedation, cognitive impairment, or withdrawal symptoms with long-term use. Buspirone can be started at 5 mg twice daily and gradually increased to 20-30 mg daily in divided doses, as seen in the guidelines for managing anxiety and agitation 1. Unlike benzodiazepines like Ativan, buspirone works by affecting serotonin and dopamine receptors in the brain, complementing the SSRI action of sertraline.
Some key points to consider when using buspirone as an alternative to Ativan include:
- Buspirone may take 2 to 4 weeks to become effective, as noted in the guidelines for anxiolytic drugs 1
- It is useful only in patients with mild to moderate agitation, making it a suitable option for patients with new onset panic attacks
- The initial dosage of buspirone is 5 mg twice daily, with a maximum dosage of 20 mg three times daily, as recommended in the guidelines for anxiolytic drugs 1
Other alternatives to Ativan for managing panic attacks include:
- Hydroxyzine, which can be started at 25 mg three times daily and works quickly for acute anxiety through antihistamine effects
- Propranolol, which can be used at 10-20 mg as needed to help control physical symptoms of panic like tachycardia and tremor These medications should be considered while the sertraline dose is optimized over time, as SSRIs typically require 4-6 weeks to reach full effectiveness and may need dose adjustments up to 100-200 mg daily for optimal panic attack control.
From the Research
Alternative Therapies to Ativan
- Cognitive-behavioral therapy (CBT) is a recommended alternative to benzodiazepines like Ativan, with strong evidence supporting its use in the treatment of panic disorder 2.
- Mindfulness, meditation, and yoga are non-pharmacological alternatives that have been studied as treatments for anxiety and can be safely recommended to patients 3.
- Buspirone, an azapirone, can be considered as a third-line agent for the treatment of panic disorder 2.
- Other antidepressants, such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors, can be considered as alternatives to SSRIs like sertraline 2.
Considerations for Treatment
- When individualizing treatment, drug dose ranges and side effect profiles need to be considered, as well as the patient's comorbid conditions 4.
- Patients with significant depression may benefit more from an antidepressant than a benzodiazepine 4.
- Combining an antidepressant with exposure therapy may produce the greatest treatment gains for panic disorder 5.