What is the recommended dosing for buspirone (anxiolytic medication) for performance anxiety, specifically for pen anxiety (likely referring to performance anxiety related to public speaking or writing)?

Buspirone Dosing for Performance Anxiety (Pen Anxiety)

For performance anxiety such as pen anxiety, buspirone should be initiated at 5 mg twice daily and gradually increased to 15-30 mg/day in divided doses (typically BID or TID), with most patients achieving optimal results at 15-30 mg/day.

Dosing Protocol

Initial Dosing

• Start with 5 mg twice daily (10 mg/day)
• Low initial dosing helps minimize side effects and allows assessment of tolerability

Titration

• Increase by 5 mg every 2-3 days as tolerated
• Target dose: 15-30 mg/day divided into 2-3 doses
• Most effective regimen options:
  • 15 mg BID (twice daily) - more convenient dosing 1
  • 10 mg TID (three times daily) - may have slightly fewer side effects 1

Maximum Dosing

• Maximum recommended dose: 30 mg/day
• Doses above 30 mg/day have not shown additional benefit and may increase side effects

Important Considerations

Onset of Action

• Unlike benzodiazepines, buspirone has a delayed onset of action
• Therapeutic effect typically begins after 1-2 weeks of consistent use 2
• Patient education about this delay is crucial for adherence

Administration Timing

• Taking with food increases bioavailability approximately 2-fold 3
• Consistent timing relative to meals is recommended for stable blood levels

Duration of Treatment

• For persistent anxiety, treatment may continue for several months
• Periodic reevaluation (every 3-6 months) is recommended to assess continued need 4

Special Populations

• Elderly patients: Start at lower doses (5 mg/day) and titrate more slowly
• Elderly patients often respond well to a mean dose of 18 mg/day 5
• Hepatic impairment: Reduce dose by 75-80% due to 15-fold higher drug exposure 3
• Renal impairment: Consider 50% dose reduction due to 2-fold higher drug exposure 3

Advantages for Performance Anxiety

• "Anxioselective" - targets anxiety without significant sedation or cognitive impairment 2
• Unlike benzodiazepines, buspirone:
  • Does not impair psychomotor or cognitive function
  • Has no additive effects with alcohol
  • Has limited potential for abuse or dependence
  • Does not cause withdrawal symptoms upon discontinuation 2, 4

Monitoring and Side Effects

Common Side Effects

• Dizziness, headache, and nausea are most common 1
• Palpitations (more common with BID dosing than TID dosing) 1
• Side effects are generally mild and transient

Drug Interactions

• Avoid concurrent use with MAOIs
• Use caution with CYP3A4 inhibitors (verapamil, diltiazem, erythromycin, itraconazole) which can substantially increase buspirone levels 3
• Rifampin can decrease buspirone levels by approximately 10-fold 3

Clinical Pearls

• Buspirone is particularly useful for performance anxiety where daytime alertness and cognitive function are essential
• Unlike benzodiazepines, buspirone can be safely used long-term without concerns about tolerance or dependence
• Patient education about delayed onset of action is crucial for treatment adherence
• BID dosing may improve compliance compared to TID dosing with similar efficacy and safety profile 1