PRN Anxiety Medications That Aren't Controlled Substances
For PRN anxiety management, hydroxyzine is the most effective non-controlled medication option, typically dosed at 25-50mg every 6-8 hours as needed. 1
First-Line Non-Controlled PRN Options
Hydroxyzine (Vistaril, Atarax)
- Mechanism: Antihistamine with anxiolytic properties
- Dosing: 25-50mg every 6-8 hours PRN for adults 1
- Benefits:
- Rapid onset (30-60 minutes)
- No addiction potential
- FDA-approved for anxiety
- Can be used long-term without dependence concerns
- Cautions:
- May cause sedation/drowsiness
- QT prolongation risk in certain populations
- Use with caution in elderly (start at lower doses)
Beta-Blockers
- Options: Propranolol (10-40mg PRN)
- Best for: Physical symptoms of anxiety (tremor, tachycardia, palpitations)
- Timing: Take 30-60 minutes before anxiety-provoking situations
- Limitations: Addresses physical symptoms but not psychological aspects of anxiety
Second-Line Non-Controlled PRN Options
Antiemetics with Anxiolytic Properties
- Prochlorperazine (Compazine): 10mg PO every 6 hours PRN 2
- Promethazine (Phenergan): 12.5-25mg PO every 4-6 hours PRN 2
- Considerations:
- Originally developed for nausea but have anxiolytic effects
- Risk of extrapyramidal symptoms (use diphenhydramine 25-50mg for dystonic reactions) 2
Other Options
- Diphenhydramine (Benadryl): 25-50mg PO every 4-6 hours PRN 2
- Primarily for sleep-related anxiety
- Significant anticholinergic effects limit regular use
Non-Pharmacological Adjuncts
These should be used alongside PRN medications:
- Breathing techniques: Box breathing (4-4-4-4 pattern)
- Progressive muscle relaxation
- Cognitive behavioral techniques: Can be self-administered during anxiety episodes
Algorithm for Selection
For mild-moderate anxiety without sedation concerns:
- Start with hydroxyzine 25mg PRN
- Increase to 50mg if needed after assessing response
For primarily physical symptoms (performance anxiety, situational):
- Propranolol 10-20mg 30-60 minutes before trigger
For anxiety with nausea:
- Consider prochlorperazine 10mg PRN
For elderly patients or those with cardiac concerns:
- Start with lower doses of hydroxyzine (10-25mg)
- Monitor for QT prolongation if on other QT-prolonging medications
Important Clinical Considerations
- Avoid benzodiazepines when possible due to dependence risk, though they remain the most effective PRN anxiolytics
- Hydroxyzine may cause drowsiness - caution patients about driving or operating machinery 1
- Monitor for QT prolongation with hydroxyzine, especially with concomitant QT-prolonging medications 1
- For patients with dyspnea and anxiety, lorazepam may be considered in palliative care settings despite being controlled 2
- SSRIs/SNRIs are first-line for chronic anxiety disorders but are not suitable for PRN use 2, 3
Special Populations
Elderly
- Start with lower doses of hydroxyzine (10-25mg)
- Higher risk of anticholinergic effects and sedation
- Monitor for falls risk
Patients with Substance Use History
- Hydroxyzine is particularly appropriate due to lack of abuse potential
- Consider more frequent follow-up to ensure effectiveness
By following this approach, you can effectively manage anxiety symptoms with non-controlled substances while minimizing risks of dependence and adverse effects.