What is the appropriate dose of Xanax (alprazolam) orally (PO) for a patient in the Emergency Department (ED) with anxiety who has not responded to hydroxyzine?

Appropriate Alprazolam Dosing for Anxiety in the Emergency Department

For a patient with anxiety in the Emergency Department who has not responded to hydroxyzine, the recommended initial dose of alprazolam is 0.5 mg orally, with the option to repeat after 30-60 minutes if needed (maximum 2 mg total in the ED setting).

Dosing Rationale and Considerations

The FDA-approved dosing for alprazolam in anxiety disorders recommends starting with 0.25 to 0.5 mg three times daily 1. However, in the emergency setting where rapid symptom control is needed, a single 0.5 mg dose is appropriate for most adult patients.

Patient-Specific Factors to Consider:

• Age: For elderly patients, start with 0.25 mg instead of 0.5 mg 2
• Prior benzodiazepine use: Patients with tolerance may require higher doses
• Comorbidities: Reduce dose in patients with hepatic impairment or respiratory conditions
• Concurrent medications: Consider potential drug interactions

Treatment Algorithm

1. First-line treatment (already tried):

   • Hydroxyzine (typically 25-50 mg PO)
   • Non-pharmacological de-escalation techniques

2. Second-line treatment (current recommendation):

   • Alprazolam 0.5 mg PO
   • Reassess in 30-60 minutes
   • If inadequate response, may administer an additional 0.5-1 mg (not exceeding 2 mg total)

3. Alternative options if alprazolam is contraindicated:

   • Lorazepam 0.5-1 mg PO/IV/IM (preferred in elderly or those with hepatic impairment) 3
   • Midazolam 2.5-5 mg subcutaneously for patients unable to take oral medications 3

Monitoring and Safety

• Monitor vital signs, particularly respiratory rate
• Assess level of sedation every 15-30 minutes after administration
• Have flumazenil available (though rarely needed) for severe respiratory depression
• Document response to treatment

Important Considerations and Cautions

• Avoid in patients with:

  • Severe respiratory depression
  • Acute narrow-angle glaucoma
  • Known hypersensitivity to benzodiazepines
  • Concurrent alcohol intoxication

• Potential for dependence: Alprazolam has a high potential for dependence, so limit ED prescriptions to 1-3 days with appropriate follow-up 4

• Paradoxical reactions: Rarely, benzodiazepines can cause increased anxiety, agitation, or aggression, particularly in elderly patients or those with underlying psychiatric conditions 2

• Discharge planning: Ensure the patient has appropriate follow-up for ongoing anxiety management, as benzodiazepines are not recommended for long-term anxiety management

Alternatives to Consider

For patients with ongoing anxiety requiring treatment beyond the ED visit, consider referring for:

• SSRI/SNRI therapy for long-term management
• Cognitive behavioral therapy
• Psychiatric evaluation for treatment-resistant anxiety

Remember that while benzodiazepines provide rapid relief of acute anxiety symptoms, they are not ideal for long-term management due to risks of tolerance, dependence, and withdrawal 4.