What are the recommended medications for anxiety used as needed (PRN)?

Recommended PRN Medications for Anxiety

For acute anxiety episodes requiring as-needed (PRN) treatment, benzodiazepines are the first-line medication choice, with lorazepam being the preferred agent at a dosage of 0.5-1 mg orally every 4-6 hours as needed (maximum 4 mg/24 hours). 1, 2

First-Line PRN Anxiety Medications

Benzodiazepines

• Lorazepam (Ativan): 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours) 1

  • For elderly or debilitated patients: Reduce dose to 0.25-0.5 mg (maximum 2 mg in 24 hours) 2
  • Oral tablets can be used sublingually for faster onset (off-label use) 1
  • For patients unable to swallow: Consider midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 1, 2

• Alprazolam (Xanax): 0.25-0.5 mg orally three times daily as needed for acute anxiety episodes 3

  • Particularly effective for episodic anxiety compared to sustained anxiety 4
  • Short half-life makes it suitable for as-needed use but increases risk of interdose anxiety 2

Second-Line PRN Anxiety Medications

• Hydroxyzine: 25-50 mg orally every 6 hours as needed 5

  • Non-addictive alternative to benzodiazepines
  • Particularly useful when sedation is desired or in patients with history of substance abuse

• Propranolol: 10-40 mg orally as needed 5

  • Particularly effective for physical symptoms of anxiety (tremor, tachycardia, sweating)
  • Best for performance anxiety or situational anxiety with prominent somatic symptoms

Important Considerations and Precautions

• Duration of use: Benzodiazepines should primarily be used for short courses (2-4 weeks) due to risks of dependence and withdrawal 2, 6

  • Long-term use is only justified in patients with chronic severe anxiety when benefits outweigh risks 4

• Patient-specific factors:

  • Elderly patients require lower doses due to increased sensitivity to effects 2
  • Avoid in patients with respiratory disorders or sleep apnea 2
  • Use with extreme caution when combined with opioids due to risk of respiratory depression 2

• Medication selection algorithm:

  1. For episodic anxiety: Short-acting benzodiazepines (lorazepam, alprazolam) 4
  2. For sustained anxiety: Consider longer-acting benzodiazepines (diazepam) 4
  3. For patients with substance abuse history: Non-benzodiazepine alternatives (hydroxyzine, buspirone) 6
  4. For predominant physical symptoms: Consider propranolol 5

• Monitoring requirements:

  • Regular assessment for effectiveness and side effects 2
  • Watch for signs of dependence or misuse 2
  • Consider adjunctive psychotherapy for long-term management 6, 5

Common Pitfalls to Avoid

• Prescribing benzodiazepines for too long: Limit to 2-4 weeks when possible 2, 6
• Inadequate dosing: Insufficient doses may not control symptoms effectively 7
• Overlooking non-pharmacological interventions: Cognitive behavioral therapy should be considered alongside PRN medications 6, 5
• Failure to reassess: Regular evaluation of continued need is essential 2
• Not addressing underlying causes: PRN medications treat symptoms but not root causes of anxiety 6