What are the recommended medications for treating anxiety in inpatients?

Recommended Medications for Treating Anxiety in Inpatients

For inpatient anxiety treatment, benzodiazepines are the first-line pharmacological intervention, with lorazepam 0.5-1 mg orally four times a day as needed (maximum 4 mg in 24 hours) being the recommended choice for patients who can swallow, or midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed for those unable to swallow. 1

First-Line Medications for Inpatient Anxiety

For Patients Able to Swallow:

• Lorazepam: 0.5-1 mg orally four times a day as needed (maximum 4 mg in 24 hours)
  • Reduce to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours)
  • Oral tablets can be used sublingually (off-label) for faster onset
  • Particularly useful for acute anxiety management in the inpatient setting

For Patients Unable to Swallow:

• Midazolam: 2.5-5 mg subcutaneously every 2-4 hours as needed
  • If needed frequently (more than twice daily), consider subcutaneous infusion via syringe driver starting with 10 mg over 24 hours
  • Reduce dose to 5 mg over 24 hours if eGFR is <30 mL/minute

Second-Line and Alternative Options

For Anxiety with Delirium:

• Haloperidol: 0.5-1 mg orally at night and every 2 hours when required
  • Can be administered subcutaneously as needed
  • Consider higher starting dose (1.5-3 mg) if patient is severely distressed
  • Consider adding a benzodiazepine if patient remains agitated

For Severe Anxiety with Delirium (Unable to Swallow):

• Levomepromazine: 12.5-25 mg subcutaneously as starting dose, then hourly as required
  • Use 6.25-12.5 mg in elderly patients
  • Maintain with subcutaneous infusion of 50-200 mg over 24 hours

For Longer-Term Anxiety Management:

• SSRIs: First-line for ongoing anxiety management 2

  • Sertraline: Start at 25-50 mg daily, increase to 50-100 mg daily after one week, target dose 50-200 mg daily
  • Escitalopram: Start at 10 mg daily
  • Allow 4-6 weeks for full therapeutic effect

• Buspirone: Alternative for patients with substance abuse concerns 3

  • Indicated for management of anxiety disorder
  • Effective for generalized anxiety with coexisting depressive symptoms
  • Not recommended for acute anxiety management due to delayed onset of action

Important Considerations and Precautions

Before Medication Administration:

• Address reversible causes of anxiety first:
  • Explore patient's concerns and anxieties
  • Ensure effective communication and orientation
  • Ensure adequate lighting
  • Treat medical causes (e.g., hypoxia, urinary retention, constipation)

Medication Safety:

• Avoid concurrent use of benzodiazepines and opioids whenever possible due to risk of fatal respiratory depression 1
• If both are necessary, consider tapering opioids first when reducing medications
• Monitor closely for excessive sedation, respiratory depression, and confusion

Special Populations:

• Elderly patients: Use reduced doses (lorazepam 0.25-0.5 mg, maximum 2 mg/24 hours)
• Renal impairment: Adjust doses for patients with eGFR <30 mL/minute
• Young adults: May be more sensitive to medication side effects, particularly with SSRIs 2

Monitoring and Follow-up

• Assess response to benzodiazepines within 30-60 minutes of administration
• For patients on SSRIs, assess for side effects within 1-2 weeks and efficacy at 4-6 weeks
• Use standardized anxiety assessment tools such as GAD-7 when possible
• Regularly reassess the need for continued medication, particularly benzodiazepines
• Plan for appropriate tapering of benzodiazepines when no longer needed (25% reduction every 1-2 weeks)

Treatment Algorithm for Inpatient Anxiety

1. Acute anxiety management:

   • Lorazepam 0.5-1 mg orally QID PRN (if able to swallow)
   • Midazolam 2.5-5 mg subcutaneously Q2-4H PRN (if unable to swallow)

2. If inadequate response or complicated by delirium:

   • Add haloperidol 0.5-1 mg orally/subcutaneously
   • Consider levomepromazine for severe cases unable to swallow

3. For ongoing anxiety management (after acute phase):

   • Transition to SSRI (sertraline or escitalopram)
   • Consider buspirone if substance abuse is a concern
   • Implement non-pharmacological interventions (CBT techniques)

This evidence-based approach prioritizes patient safety while providing effective anxiety management in the inpatient setting.