Is Buspar (buspirone) safe to use while tapering an older adult off Xanax (alprazolam)?

Buspirone is Safe and Beneficial During Alprazolam Tapering in Older Adults

Yes, buspirone (Buspar) is safe to use while tapering an older adult off alprazolam (Xanax) and may actually facilitate the tapering process by helping manage anxiety symptoms during withdrawal. 1

Benefits of Using Buspirone During Benzodiazepine Tapering

• Buspirone does not affect reaction time, vigilance, psychomotor speed, or memory function in older adults, making it a safer alternative to benzodiazepines 2
• Buspirone can help facilitate benzodiazepine discontinuation with success rates higher than placebo (67.9% vs 37.5%) when used during the tapering process 1
• Unlike benzodiazepines, buspirone is not associated with cognitive impairment, reduced mobility, unsafe driving skills, falls, fractures, or addiction in older adults 3

Risks of Benzodiazepines in Older Adults

• Benzodiazepines like alprazolam are considered high-risk medications in older adults according to Beers Criteria and should be tapered/avoided when possible 3
• Benzodiazepines cause sedation, cognitive impairment, unsafe mobility with injurious falls, motor skill impairment, and can lead to dependence and withdrawal syndromes 3
• Long-term benzodiazepine use in older adults is associated with significant adverse effects despite limited evidence of ongoing benefit 4

Recommended Approach for Alprazolam Tapering with Buspirone

1. Start buspirone before beginning alprazolam taper

   • Begin with low doses (e.g., 5 mg three times daily) and gradually increase as needed 2
   • Allow 2-4 weeks for buspirone to reach full therapeutic effect before initiating alprazolam taper 1

2. Implement gradual alprazolam tapering schedule

   • Reduce alprazolam dose by approximately 25% per week, but consider a more gradual approach for long-term users 3
   • For chronic users, aim for withdrawal over a period of 1-6 months to minimize withdrawal symptoms 5
   • The EMPOWER approach recommends gradual reduction over many weeks for better success rates 3

3. Monitor for withdrawal symptoms

   • Watch for rebound anxiety, insomnia, irritability, sensory hypersensitivity, and rarely seizures 3
   • If severe withdrawal symptoms occur, temporarily slow the taper rather than abandoning it 5

4. Consider adjunctive non-pharmacological approaches

   • Cognitive-behavioral therapy significantly improves success rates when combined with medication taper (85% success vs 48% with taper alone) 6
   • Other helpful approaches include patient education about benzodiazepine risks, sleep hygiene, relaxation techniques, and supportive psychotherapy 3

Important Considerations and Precautions

• Buspirone is not a direct substitute for benzodiazepines and works through different mechanisms (5-HT1A receptor partial agonist vs GABA receptor modulation) 1
• Buspirone does not prevent acute benzodiazepine withdrawal symptoms, so gradual tapering of alprazolam is still essential 5
• Older adults may require lower initial doses of buspirone due to age-related changes in pharmacokinetics 3
• Avoid concurrent use of other CNS depressants like opioids during the tapering process, as this increases risk of adverse effects 3

Monitoring and Follow-up

• Regular follow-up during the tapering process is essential to assess for withdrawal symptoms and adjust the taper schedule as needed 5
• Continue buspirone for several months after successful alprazolam discontinuation to stabilize anxiety symptoms 1
• Monitor for improved cognitive function, mobility, and quality of life after successful benzodiazepine discontinuation 6