What is the recommended dosing for Buspirone (anxiolytic medication) for anxiety?

Buspirone Dosing for Anxiety

Start buspirone at 5 mg twice daily (10 mg/day total) and titrate by 5 mg every 2-3 days until reaching the therapeutic range of 15-30 mg/day in divided doses, with a maximum of 60 mg/day (20 mg three times daily). 1, 2

Initial Dosing Strategy

• Begin with 5 mg twice daily to minimize side effects while establishing baseline tolerability 1, 2
• This conservative starting dose is recommended by the American Academy of Family Physicians and reduces the risk of early discontinuation 1, 2

Titration Protocol

• Increase by 5 mg/day every 2-3 days as tolerated until therapeutic effect is achieved 1, 2
• Most patients require 15-30 mg/day in divided doses for optimal anxiolytic effect 1, 2, 3, 4
• The absolute maximum dose is 60 mg/day (typically given as 20 mg three times daily), though doses above 30 mg/day are rarely needed 1, 2

Dosing Frequency Options

• Either twice daily (BID) or three times daily (TID) dosing is acceptable at equivalent total daily doses 5
• BID dosing (e.g., 15 mg twice daily) may offer better compliance without compromising safety or tolerability compared to TID dosing (e.g., 10 mg three times daily) 5
• The only notable difference is a slightly higher incidence of palpitations with BID dosing (5% vs 1%) 5

Critical Timing Consideration

• Counsel patients that therapeutic effect requires 2-4 weeks to become apparent 1, 2, 4
• This "lagtime" is essential to communicate upfront to maintain compliance and prevent premature discontinuation 1, 2, 4
• Evaluate response at 4 weeks on therapeutic dose (15-30 mg/day) before considering dose escalation 2

Special Population Adjustments

• Elderly or frail patients: start at 2.5-5 mg twice daily and titrate more gradually 1, 2
• Hepatic impairment: substantially reduce dose and monitor closely, as buspirone concentrations increase 15-fold in hepatic dysfunction 1, 6
• Renal impairment: use lower doses and titrate cautiously, as concentrations double in renal dysfunction 1, 6

Common Pitfalls to Avoid

• Do not discontinue before 4 weeks at therapeutic dose, as inadequate trial duration is the most common reason for perceived treatment failure 1, 2
• Food increases absorption 2-fold, so advise consistent administration either always with food or always without food 6
• Avoid combining with CYP3A4 inhibitors (verapamil, diltiazem, erythromycin, itraconazole) as they substantially increase buspirone levels, while rifampin decreases levels 10-fold 6

Long-Term Management

• Buspirone can be safely used for up to one year without evidence of withdrawal syndrome upon discontinuation 3
• Periodically reevaluate the need for continued therapy when treatment extends beyond several months 3