What are the recommended PRN (as needed) medications for anxiety management?

Recommended PRN Medications for Anxiety Management

Benzodiazepines are the first-line PRN medications for acute anxiety management, with lorazepam (0.5-1 mg PO/IV every 4 hours PRN) being the recommended option for most patients. 1

First-Line PRN Anxiety Medications

Benzodiazepines

• Lorazepam: 0.5-1 mg PO/IV every 4 hours PRN 2, 1

  • Preferred for anxiety-naive patients
  • Can be administered via multiple routes (oral, IV, subcutaneous)
  • Maximum dose: 2 mg per administration 1

• Midazolam: 2.5 mg subcutaneous/IV every hour PRN 1

  • Maximum dose: 5 mg per administration
  • Shorter acting than lorazepam
  • Useful for rapid anxiety control

• Alprazolam: Indicated for generalized anxiety disorder and panic disorder 3

  • Effective for short-term relief of anxiety symptoms
  • Also effective for panic disorder with or without agoraphobia

Second-Line/Alternative Options

Non-Benzodiazepine Antipsychotics

• Quetiapine: 25 mg PRN 1

  • First-line non-benzodiazepine option
  • Lower risk of dependence than benzodiazepines
  • Particularly useful for anxiety with delirium
  • Side effects: sedation, orthostatic hypotension

• Aripiprazole: 5 mg oral/IM PRN 1

  • Lower risk of extrapyramidal side effects
  • Side effects: headache, agitation, insomnia, dizziness

• Olanzapine/Risperidone: Alternative antipsychotic options 1

  • Should not be combined with benzodiazepines due to risk of oversedation

Other Anxiolytics

• Buspirone: For generalized anxiety disorder 4, 5
  • Not effective for PRN use due to delayed onset of action
  • Requires regular dosing (15-30 mg/day) 6
  • No risk of dependence or withdrawal
  • Not suitable for acute anxiety management

Clinical Decision Algorithm

1. Assess anxiety severity and presentation:

   • For acute severe anxiety: Benzodiazepines are preferred
   • For mild-moderate anxiety: Consider non-benzodiazepine options

2. Consider contraindications to benzodiazepines:

   • Severe pulmonary insufficiency
   • Severe liver disease
   • Myasthenia gravis
   • History of substance abuse

3. Special populations:

   • Elderly patients: Start with lower doses (e.g., lorazepam 0.25-0.5 mg)
   • Patients with delirium: Consider quetiapine
   • Patients with Parkinson's disease: Avoid haloperidol 1

Safety Considerations and Monitoring

• Benzodiazepines:

  • Monitor for excessive sedation and respiratory depression
  • Increased risk of falls, particularly in elderly patients 1
  • Risk of dependence with prolonged use 7

• Antipsychotics:

  • Monitor orthostatic blood pressure 1
  • Avoid in patients with baseline QT prolongation
  • Watch for extrapyramidal symptoms

Common Pitfalls to Avoid

• Using benzodiazepines as long-term treatment for chronic anxiety disorders 7, 8
• Failing to implement non-pharmacological interventions alongside medication 1
• Excessive dosing in elderly or medically compromised patients 1
• Not monitoring for QTc prolongation with certain antipsychotics 1
• Switching too quickly between antipsychotics without proper cross-titration 1

Non-Pharmacological Interventions

Always implement alongside PRN medications:

• Reorientation strategies
• Cognitive stimulation
• Sleep optimization
• Early mobilization when appropriate
• Ensuring use of sensory aids (hearing aids, eyeglasses) 1

For long-term anxiety management, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are recommended as first-line pharmacotherapy, along with cognitive behavioral therapy 8.