What is the recommended dose of quetiapine (Seroquel) at bedtime for anxiety?

Quetiapine Dosing for Anxiety at Bedtime

For anxiety disorders, start quetiapine at 25 mg orally at bedtime, with potential titration up to 50-300 mg/day based on response and tolerability. 1, 2

Evidence-Based Dosing Recommendations

Starting Dose and Titration

• Initial dose: 25 mg at bedtime for anxiety-related conditions, particularly in delirium management and agitation contexts 1
• The FDA-approved dosing for quetiapine immediate-release typically begins at 25 mg twice daily for most psychiatric indications, but bedtime-only dosing at 25 mg is appropriate for anxiety 2
• For generalized anxiety disorder (GAD), effective doses range from 50-300 mg/day, with studies showing consistent efficacy around 150 mg/day 3

Dose Escalation Strategy

• If scheduled dosing is required beyond PRN use, increase to twice-daily dosing (every 12 hours) rather than maintaining single bedtime dosing 1
• Titration should occur gradually to minimize sedation, orthostatic hypotension, and dizziness—the most common side effects 1
• For augmentation therapy in treatment-resistant anxiety with antidepressants, mean effective doses around 50 mg/day (range 50-300 mg/day) have demonstrated benefit 4, 5

Clinical Context and Efficacy

Anxiety Disorder Subtypes

• GAD: 150 mg/day shows consistent efficacy in placebo-controlled trials 3
• Comorbid bipolar disorder with panic/GAD: 50-300 mg/day (mean 186 mg/day) produces rapid sustained anxiety improvement 6
• Social anxiety disorder: Up to 400 mg/day has been studied, though evidence is less robust than for GAD 7
• Augmentation for partial SSRI response: Mean dose 50 mg/day shows significant benefit over placebo 4

Important Clinical Considerations

Sedation profile: Quetiapine is notably sedating, making bedtime dosing logical for anxiety with insomnia 1

Lower extrapyramidal symptoms (EPS) risk: Compared to other atypical antipsychotics, quetiapine has reduced EPS liability 1

Metabolic effects: Even low doses may cause weight gain and triglyceride elevation across psychiatric disorders 3

Special Population Adjustments

Elderly or Debilitated Patients

• Start at lower doses (12.5-25 mg) and titrate more slowly 1, 2
• Reduce maximum daily dose to avoid oversedation and falls risk 1
• Consider starting at 50 mg/day with 50 mg increments for elderly patients per FDA guidance 2

Hepatic Impairment

• Initial dose: 25 mg/day with daily increments of 25-50 mg to effective dose 2

Renal Impairment

• Dose reduction recommended in severe renal impairment 1

Critical Safety Warnings

Orthostatic hypotension: Monitor blood pressure, particularly during initial titration and dose increases 1

Combination with benzodiazepines: Risk of oversedation and respiratory depression; use caution if combining 1

Off-label use caveat: Quetiapine is not FDA-approved for anxiety disorders—all anxiety indications represent off-label use 2

Metabolic monitoring: Even at low doses (25-50 mg), monitor weight, glucose, and lipids due to metabolic side effects 3

Practical Algorithm

1. Start 25 mg at bedtime for anxiety symptoms 1
2. Assess response after 3-7 days: If inadequate, increase to 50 mg at bedtime 2
3. If further titration needed: Increase by 25-50 mg increments every 3-7 days 2
4. Target dose for GAD: 150 mg/day (can give as single bedtime dose or divided) 3
5. Maximum for anxiety: 300 mg/day in most cases 6, 5
6. Reassess need for continued treatment after achieving symptom control 2

Common Pitfalls to Avoid

• Avoid rapid titration: This increases orthostatic hypotension and sedation risk 1
• Don't ignore metabolic effects at low doses: Weight gain can occur even at 25-50 mg/day 3
• Recognize lack of FDA approval: Document rationale for off-label use in anxiety disorders 2
• Monitor for paradoxical agitation: Though rare, can occur with quetiapine 1