What is a suitable PRN (as-needed) medication for anxiety in a patient with bipolar 1 disorder, currently taking Abilify (aripiprazole) and lithium, who experiences sedation with hydroxyzine?

PRN Medication Options for Anxiety in a 17-Year-Old with Bipolar 1 Disorder

For a 17-year-old with bipolar 1 disorder and anxiety who experiences sedation with hydroxyzine, low-dose lorazepam (0.25-0.5mg) would be the most appropriate PRN anxiety medication while continuing Abilify and lithium.

Considerations for PRN Anxiety Medication Selection

• PRN benzodiazepines like lorazepam can be appropriate for managing anxiety symptoms in patients with bipolar disorder when used cautiously and at the lowest effective dose 1
• Benzodiazepines should be used at lower doses in younger patients or when co-administered with other psychotropic medications like antipsychotics 1
• The combination of Abilify (aripiprazole) and lithium is an evidence-based approach for bipolar 1 disorder management, providing mood stabilization while minimizing metabolic side effects 2, 3
• Aripiprazole has shown efficacy for anxiety symptoms in open-label trials, suggesting the current regimen may already provide some anxiety coverage 4

Recommended PRN Options

• First choice: Low-dose lorazepam (0.25-0.5mg PRN)

  • Can be administered orally or sublingually for rapid onset 1
  • Lower doses minimize sedation while still providing anxiolytic effects 1
  • Should be used at the lowest effective dose to minimize risk of tolerance and dependence 1

• Alternative option: Low-dose midazolam

  • Starting with 0.5-1mg PRN if lorazepam is ineffective 1
  • Provides rapid onset but with potentially more sedation than lorazepam 1

Important Clinical Considerations

• Benzodiazepines should be prescribed with clear instructions regarding:

  • Maximum daily dosage (typically not exceeding 2mg lorazepam equivalent) 1
  • Frequency limitations (e.g., not more than 2-3 times weekly for PRN use) 1
  • Avoiding use with alcohol or other CNS depressants 1

• Regular monitoring is essential to:

  • Assess for signs of tolerance or dependence 1
  • Evaluate ongoing need versus potential for discontinuation 1
  • Monitor for any mood destabilization 2

Medications to Avoid

• Antidepressant monotherapy is not recommended as it may trigger manic episodes or rapid cycling in bipolar disorder 2
• High-dose benzodiazepines should be avoided due to increased risk of sedation, especially when combined with antipsychotics like Abilify 1
• Sedating antihistamines (like hydroxyzine) are clearly not tolerated by this patient due to excessive sedation 1

Special Considerations for Adolescents with Bipolar Disorder

• The American Academy of Child and Adolescent Psychiatry recognizes lithium as the only FDA-approved agent for bipolar disorder in adolescents (ages 12+), though atypical antipsychotics like aripiprazole are commonly used 2
• When treating comorbid anxiety in bipolar disorder, it's essential to maintain mood stabilization as the primary goal while addressing anxiety symptoms 2
• Regular follow-up to assess both anxiety symptoms and overall mood stability is crucial in this age group 2