What is more effective for sleep, Ativan (lorazepam) or Xanax (alprazolam) at a low dose?

Neither Ativan (Lorazepam) nor Xanax (Alprazolam) is Recommended for Sleep

Neither lorazepam (Ativan) nor alprazolam (Xanax) is recommended as a first-line treatment for insomnia due to their significant risks of dependence, tolerance, and adverse effects that outweigh potential benefits for sleep. 1

Evidence Against Benzodiazepines for Sleep

The 2020 VA/DoD Clinical Practice Guidelines explicitly advise against using benzodiazepines for chronic insomnia disorder. While benzodiazepines can improve sleep parameters compared to placebo, their widely known harms and adverse effects substantially outweigh the benefits, including:

• Risk for dependency and diversion
• Falls and cognitive impairment in older patients
• Hypoventilation in patients with respiratory conditions
• Adverse effects in neuromuscular diseases 1

Preferred Pharmacological Options for Sleep (If Needed)

If medication is necessary for sleep disturbances, current guidelines recommend:

1. Non-pharmacological approaches first - Cognitive Behavioral Therapy for Insomnia (CBT-I) is more effective than pharmacotherapy for chronic insomnia, especially for long-term outcomes 1

2. If medication is required:

   • Low-dose doxepin (3 or 6 mg) - Improves sleep with fewer adverse events
   • Non-benzodiazepine receptor agonists (zolpidem, zaleplon, eszopiclone) at the lowest effective dose for the shortest duration 1

Lorazepam-Specific Concerns

If lorazepam must be used (which is not recommended):

• FDA labeling indicates for insomnia due to anxiety, a single daily dose of 2-4 mg may be given at bedtime 2
• Research shows significant rebound insomnia upon withdrawal, with sleep disturbance several times worse than the initial improvement 3
• Studies demonstrate hangover effects, anterograde amnesia, and increased daytime anxiety with continued use 3, 4
• Morning anxiety and confusion can occur even at low doses 5

Practical Considerations

If a patient absolutely requires short-term pharmacological intervention for sleep:

1. Start with non-benzodiazepine options as they have better safety profiles
2. Use for the shortest possible duration - ideally less than 2 weeks 1
3. Implement strict sleep hygiene measures concurrently:
   • Consistent sleep-wake schedule
   • Avoid caffeine, nicotine, and alcohol
   • Limit bedroom activities to sleep and sex
   • Avoid daytime napping 1

Special Populations

• Elderly patients: Both lorazepam and alprazolam carry increased risks of falls, cognitive impairment, and adverse effects 6
• Patients with anxiety: If sleep disturbance is secondary to anxiety, the National Comprehensive Cancer Network suggests short-acting benzodiazepines may be considered, but non-benzodiazepine alternatives are still preferred 6

Bottom Line

Neither Ativan nor Xanax is recommended for sleep. The evidence strongly supports using non-pharmacological approaches first, followed by non-benzodiazepine alternatives if medication is necessary. The risks of dependence, tolerance, rebound insomnia, and adverse effects make benzodiazepines a poor choice for managing sleep problems.