What benzodiazepines (BZDs) are used to treat anxiety symptoms and what are their recommended doses?

Benzodiazepines for Anxiety Symptoms: Selection and Dosing

For anxiety symptoms, benzodiazepines should be used as short-term therapy with lorazepam (0.5-1 mg orally three times daily) or alprazolam (0.25-0.5 mg orally three times daily) as first-line options, with careful tapering when discontinuing to prevent withdrawal symptoms. 1, 2

First-Line Benzodiazepine Options

Lorazepam

• Initial dose: 0.5-1 mg orally three to four times daily 2
• Usual range: 2-6 mg/day in divided doses 2
• Maximum dose: 10 mg/day 2
• Advantages: Medium duration of action, suitable for both anxiety and insomnia 3
• Elderly/debilitated patients: Start with 1-2 mg/day in divided doses 2

Alprazolam

• Initial dose: 0.25-0.5 mg orally three times daily 1
• Titration: May increase at intervals of 3-4 days 1
• Maximum dose: 4 mg/day for anxiety disorders 1
• For panic disorder: May require higher doses (5-6 mg/day average, up to 10 mg/day in some cases) 1

Second-Line Options

• Diazepam: Effective for acute stress reactions and episodic anxiety 3
• Clonazepam: Long half-life allows less frequent dosing and more continuous control of anxiety 4

Duration of Treatment

• Benzodiazepines should primarily be used for:
  • Transient or short-term insomnia (limited to a few days) 3
  • Acute stress reactions 3
  • Episodic anxiety 3
  • Short courses (2-4 weeks maximum) 3
• Long-term use should be avoided due to risks of dependence and withdrawal 5, 3

Discontinuation Protocol

• Never discontinue benzodiazepines abruptly due to risk of withdrawal symptoms 1, 2
• Recommended tapering schedule:
  • Alprazolam: Decrease by no more than 0.5 mg every 3 days 1
  • Lorazepam: Gradual taper to avoid withdrawal reactions 2
  • Some patients may require even slower tapering 1
  • If withdrawal symptoms occur, pause taper or temporarily increase to previous dose 2

Clinical Considerations and Cautions

• Dependence risk: Around half of patients prescribed benzodiazepines are treated continuously for at least 12 months, which is not recommended by guidelines 5
• Elderly patients: Use reduced doses (lorazepam 0.25-0.5 mg, maximum 2 mg/day) due to increased sensitivity to effects 5
• Respiratory concerns: Benzodiazepines can cause dangerous respiratory depression when combined with opioids 5
• Cognitive effects: May cause psychomotor impairment, especially in elderly patients 3
• Paradoxical reactions: Some patients may experience increased agitation or excitement 3

Specific Clinical Scenarios

• Acute anxiety or agitation in patients unable to swallow: Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 5
• Anxiety in COVID-19 patients: Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours) 5
• Alcohol withdrawal syndrome: Benzodiazepines are first-line treatment, with lorazepam 1-4 mg orally/IV/IM every 4-8 hours recommended for patients with liver impairment 5

Monitoring and Follow-up

• Assess response to treatment and presence of side effects at each visit 5
• Monitor for signs of dependence or misuse 5, 3
• Reassess need for continued treatment frequently 1
• Consider adjunctive or alternative treatments such as cognitive behavioral therapy for longer-term management 5