What is the best option for a patient with increased anxiety who is stable on their current regimen?

Management of Increased Anxiety in a Stable Patient

For a patient who is stable on their current regimen but experiencing increased anxiety, the best option is to add a benzodiazepine such as lorazepam 0.5-1 mg orally up to four times daily as needed for short-term management of anxiety symptoms. 1

First-line Pharmacological Options

• Benzodiazepines are appropriate for short-term management of anxiety symptoms in patients who are otherwise stable on their medication regimen 1
• Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours) is recommended for anxiety or agitation in patients who can swallow 1
• For elderly or debilitated patients, reduce the dose to 0.25-0.5 mg (maximum 2 mg in 24 hours) 1
• Oral lorazepam tablets can be used sublingually (off-label) for faster onset of action 1

Alternative Pharmacological Options

• If the patient is unable to tolerate benzodiazepines or has a history of substance abuse, consider adding buspirone for the management of anxiety disorder 2
• Buspirone is particularly effective in patients with generalized anxiety disorder who have coexisting depressive symptoms 2
• Consider increasing the dose of existing medications if they have anxiolytic properties; for example, if the patient is on aripiprazole 5 mg, consider increasing to 10 mg daily 3
• If the patient is on mirtazapine 15 mg, consider increasing to 30 mg at bedtime for better anxiolytic effects 3

Non-pharmacological Approaches

• Cognitive behavioral therapy (CBT) should be offered alongside medication management, as it has demonstrated efficacy for anxiety disorders 1
• Individual CBT sessions are preferred over group therapy due to superior clinical and health-related economic effectiveness 1
• If the patient does not want face-to-face CBT, self-help with support based on CBT principles is suggested 1
• CBT should include psychoeducation, cognitive restructuring, and gradual exposure to anxiety-provoking situations 1

Monitoring and Follow-up

• Monitor for potential side effects of benzodiazepines, including sedation, cognitive impairment, and risk of dependence 3
• Limit benzodiazepine use to short-term management (2-4 weeks) to prevent dependence 4
• Assess response to treatment within 2-4 weeks 3
• Watch for drug interactions, particularly between existing medications and newly added anxiolytics 3

Important Considerations and Cautions

• Avoid adding another SSRI or SNRI if the patient is already on serotonergic medications due to the risk of serotonin syndrome 3
• Benzodiazepines should not be used routinely for long-term management due to risks of dependence and tolerance 1, 4
• Extended-release formulations of benzodiazepines may be advantageous in some patients as they allow for more consistent serum drug concentrations 4
• After remission of anxiety symptoms, medications should be continued for 6 to 12 months to prevent relapse 5

Special Populations

• For patients with comorbid depression and anxiety, antidepressants (SSRIs or SNRIs) are preferred over benzodiazepines 6
• For patients with a history of substance abuse, low-dose antipsychotics may be valuable alternatives to benzodiazepines 7
• For elderly patients, use lower starting doses of benzodiazepines and monitor closely for side effects 1