What is a suitable benzodiazepine alternative for a patient presenting with anxiety who is already taking Lamictal (lamotrigine) and Abilify (aripiprazole)?

Benzodiazepine Alternatives for Anxiety in Patients on Lamictal and Abilify

Buspirone is the most appropriate benzodiazepine alternative for a patient with anxiety who is already taking lamotrigine (Lamictal) and aripiprazole (Abilify). 1, 2

First-Line Alternatives to Benzodiazepines

• Buspirone (BuSpar) is the preferred first-line benzodiazepine alternative due to its:

  • Specific anxiolytic properties without sedation or dependence risk 1
  • Lack of interaction with lamotrigine or aripiprazole 2
  • Effectiveness for generalized anxiety disorder comparable to benzodiazepines 3
  • Starting dose: 5 mg twice daily, titrated to 15-30 mg daily in divided doses 1

• Optimize current aripiprazole (Abilify) dose:

  • Consider increasing aripiprazole from current dose to 10 mg daily if currently on a lower dose 4
  • Aripiprazole has demonstrated efficacy as an anxiolytic at higher doses 5
  • Monitor for potential side effects including headache, agitation, insomnia, dizziness 4

Second-Line Options

• Hydroxyzine (antihistamine with anxiolytic properties):

  • Effective for short-term anxiety management 2
  • Dosage: 25-50 mg every 6 hours as needed 2
  • Caution: May cause sedation, anticholinergic effects 2

• Pregabalin (anticonvulsant):

  • Effective for generalized anxiety disorder 2
  • Starting dose: 75 mg twice daily, may increase to 300-600 mg/day 2
  • Monitor for potential drug interactions with lamotrigine 2

Important Cautions and Considerations

• Avoid benzodiazepines whenever possible due to:

  • Risk of respiratory depression, especially when combined with other CNS depressants 6
  • CDC guidelines strongly recommend against concurrent use of benzodiazepines with other psychotropic medications 6
  • Risk of dependence and withdrawal 6

• Avoid adding SSRIs or SNRIs due to:

  • Potential risk of serotonin syndrome when combined with current medications 4
  • Possible drug interactions with lamotrigine and aripiprazole 4

Monitoring and Follow-up

• Assess response to buspirone within 2-4 weeks (note that full anxiolytic effect may take 3-4 weeks) 1
• Monitor for common side effects of buspirone including nausea, dizziness, and headache 7
• If buspirone is ineffective after 4-6 weeks at therapeutic doses, consider second-line options 2
• Regular follow-up appointments to assess treatment efficacy and side effects 4

Special Considerations for This Medication Combination

• The combination of lamotrigine and aripiprazole is commonly used for mood disorders with comorbid anxiety 4
• Buspirone has minimal drug interactions with either medication, making it particularly suitable 1
• Patients previously exposed to benzodiazepines may find buspirone less immediately effective 7
• Educate patient that buspirone's onset of action is gradual (1-2 weeks) compared to benzodiazepines 1