What medications are used to treat acute anxiety?

Medications for Acute Anxiety

Benzodiazepines are the first-line medication treatment for acute anxiety due to their rapid onset of action, with alprazolam being particularly effective for panic attacks and acute anxiety episodes. 1

First-Line Medications

Benzodiazepines

Benzodiazepines work quickly to relieve anxiety symptoms and are the preferred medication for acute anxiety episodes due to their rapid onset of action.

• Alprazolam (Xanax)

  • Most extensively studied for panic disorder and acute anxiety 1
  • Dosage: 0.25-0.5mg every 8 hours as needed 1
  • Particularly effective for panic attacks with symptoms like palpitations, shortness of breath, chest pain, and fear of dying 1
  • Available in extended-release formulation (Alprazolam-XR) for once-daily dosing with better tolerability 2

• Lorazepam (Ativan)

  • Comparable efficacy to alprazolam for panic disorder 3
  • Shorter half-life makes it suitable for episodic anxiety 4
  • Dosage: 0.5-2mg every 8 hours as needed

• Diazepam (Valium)

  • Equally effective as alprazolam for panic disorder 5
  • Longer half-life makes it more suitable for sustained anxiety 4
  • Less frequent dosing required

Second-Line Medications

Non-Benzodiazepine Anxiolytics

• Buspirone
  • Not effective for acute anxiety due to delayed onset of action (2-3 weeks) 6
  • More suitable for chronic generalized anxiety disorder
  • Does not have the dependence risk of benzodiazepines

Important Considerations

Benefits of Benzodiazepines

• Rapid onset of action (minutes to hours)
• High efficacy for symptom relief
• Well-established safety profile when used appropriately

Limitations and Risks

• Dependence and tolerance: Risk increases with duration of use 1, 4
• Sedation and cognitive impairment: Common side effects, especially at initiation 1
• Not recommended for long-term use: Short-term use (2-4 weeks) is generally recommended 4
• Withdrawal symptoms: Can occur even after short-term use, especially with shorter-acting agents 1

Common Side Effects

• Drowsiness (41% with alprazolam vs. 21.6% with placebo) 1
• Light-headedness (20.8% with alprazolam vs. 19.3% with placebo) 1
• Impaired coordination (40.1% with alprazolam in panic disorder patients) 1
• Memory impairment (33.1% with alprazolam in panic disorder patients) 1

Treatment Algorithm

1. Assess severity and nature of anxiety:

   • For panic attacks or severe acute anxiety: Benzodiazepines
   • For chronic anxiety without acute episodes: Consider non-benzodiazepine options

2. Select appropriate benzodiazepine:

   • For episodic anxiety/panic attacks: Alprazolam or lorazepam
   • For more sustained anxiety: Diazepam

3. Dosing considerations:

   • Start with lowest effective dose
   • Use as needed rather than scheduled dosing when possible
   • Limit duration to shortest period necessary (ideally less than 4 weeks)

4. Monitor for:

   • Efficacy in relieving symptoms
   • Side effects, particularly sedation and cognitive impairment
   • Signs of dependence or tolerance

5. Plan for discontinuation:

   • Gradual tapering to avoid withdrawal symptoms
   • Consider transition to longer-term treatment options if anxiety persists

Special Considerations

• Elderly patients: Use lower doses due to increased sensitivity to side effects 1
• Patients with substance use history: Higher risk of misuse; consider alternative treatments
• Drug interactions: Benzodiazepines may interact with other CNS depressants, including alcohol 1

For patients requiring longer-term treatment, SSRIs or SNRIs should be considered as they are more appropriate for chronic anxiety management 7, though they are not effective for acute anxiety episodes due to their delayed onset of action.