What is the preferred medication between Diazepam (lorazepam) and Ativan (lorazepam) for treating panic attacks?

Lorazepam vs Diazepam for Panic Attacks

Lorazepam is preferred over diazepam for treating panic attacks due to its more favorable pharmacokinetic profile, including more predictable absorption, shorter half-life, and lack of active metabolites. 1

Pharmacological Comparison

Lorazepam (Ativan)

• Pharmacokinetics: Fast onset of action, rapid and complete absorption, no active metabolites 2
• Dosing: Starting dose of 0.5-1mg as needed for acute panic attacks, maximum 2-3mg/day divided into 2-3 doses 1
• Administration: Can be given orally, sublingually, subcutaneously, or intravenously 2
• Advantages: More predictable absorption when given intramuscularly compared to diazepam 2

Diazepam (Valium)

• Pharmacokinetics: Longer half-life, erratic absorption when given intramuscularly 2
• Disadvantages: Less predictable blood levels, which can affect consistent symptom control 2

Evidence-Based Recommendation

The World Health Organization guidelines recommend lorazepam over diazepam for acute anxiety management 1. This preference is based on lorazepam's:

• More consistent absorption
• Shorter half-life (allowing better dose titration)
• Absence of active metabolites (reducing risk of drug accumulation)

While both medications have demonstrated efficacy in treating panic disorder 3, the pharmacokinetic advantages of lorazepam make it the preferred option for acute panic attacks.

Clinical Application

When to Use Lorazepam

• For acute panic attacks requiring rapid symptom control
• When predictable absorption and duration of action are important
• In patients with hepatic impairment (as lorazepam doesn't rely on liver metabolism to the same extent as diazepam)

Important Considerations

• Short-term use: Benzodiazepines should be used for short-term relief only in patients without a history of dependency 1
• Monitoring: Watch for common side effects including:
  • Increased risk of falls
  • Drowsiness
  • Dizziness
  • Potential for paradoxical agitation

Alternative Approaches

For long-term management of panic disorder, consider:

1. SSRIs or SNRIs as first-line treatment (combined with CBT) 1
2. Cognitive behavioral therapy (structured with approximately 14 sessions over 4 months) 1
3. Non-pharmacological approaches including regular exercise, sleep hygiene, and stress management techniques 1

Caution

Benzodiazepines can cause tolerance and dependence with prolonged use 4. Discontinuation may be difficult and associated with rebound and withdrawal symptoms, particularly with shorter-acting benzodiazepines like alprazolam 5.