What is the recommended dose titration for Buspar (buspirone)?

Buspar (Buspirone) Dose Titration

Start buspirone at 5 mg twice daily (total 10 mg/day) and increase by 5 mg per day every 2-3 days until reaching the target dose of 15-30 mg/day divided into 2-3 doses, with a maximum of 60 mg/day. 1

Initial Dosing Strategy

• Begin with 5 mg twice daily (morning and evening) for the first few days 1
• This low starting dose minimizes initial side effects and allows assessment of tolerability 2
• Take doses with food to optimize absorption, as food increases buspirone bioavailability approximately 2-fold 3

Titration Schedule

• Increase by 5 mg per day every 2-3 days until therapeutic effect is achieved 1
• Most patients respond to 15-30 mg/day divided into 2-3 doses 1, 4
• The typical maintenance dose is 15 mg twice daily (30 mg/day total) 2, 4
• Maximum recommended dose is 60 mg/day (can be given as 20 mg three times daily) 1

Dosing Frequency Options

• Both twice-daily (BID) and three-times-daily (TID) regimens are equally effective at the same total daily dose 5
• For 30 mg/day: either 15 mg BID or 10 mg TID produces equivalent anxiety reduction 5
• BID dosing may improve adherence while maintaining efficacy 5

Critical Timing Considerations

• Expect a 1-2 week lag time before anxiolytic effects become apparent 2
• This delayed onset differs markedly from benzodiazepines and requires patient counseling to maintain compliance 2
• Continue titration based on tolerability during this initial period, not on immediate symptom response 2
• Reassess need for continued therapy after 6-12 months of treatment, as long-term anxiolytic use should be periodically evaluated 4

Dose Adjustments for Special Populations

Hepatic Impairment

• Reduce dose by 50-75% in patients with hepatic dysfunction 3
• Buspirone exposure increases 15-fold and half-life doubles in hepatic impairment 3
• Start with 5 mg once daily and titrate very slowly 3

Renal Impairment

• Reduce dose by approximately 50% in patients with significant renal dysfunction 3
• Both buspirone and its active metabolite 6-hydroxybuspirone accumulate with renal impairment 3
• Monitor closely for increased side effects 3

Elderly Patients

• Use standard dosing but monitor more carefully for side effects 1
• The 5 mg twice daily starting dose is particularly appropriate for older adults 1

Drug Interaction Considerations

Avoid or significantly reduce buspirone dose when coadministered with:

• CYP3A4 inhibitors (verapamil, diltiazem, erythromycin, itraconazole) increase buspirone levels substantially 3
• Consider starting at 2.5 mg twice daily if these medications cannot be avoided 3

Increase buspirone dose when coadministered with:

• Rifampin decreases buspirone levels approximately 10-fold 3
• May require doses at the higher end of the therapeutic range 3

Discontinuation

• Buspirone can be stopped abruptly without withdrawal syndrome even after prolonged use (>6 months) 4
• No tapering schedule is required, unlike benzodiazepines 4
• This represents a significant safety advantage over other anxiolytics 4

Common Pitfalls to Avoid

• Do not expect immediate anxiolytic effects - patients must understand the 1-2 week onset delay to prevent premature discontinuation 2
• Do not substitute buspirone for benzodiazepines in patients with acute anxiety - it is ineffective for immediate symptom relief 2
• Do not underdose - many patients require 20-30 mg/day for optimal response, not just the 15 mg/day starting point 4
• Do not forget that 6-hydroxybuspirone levels are 40-fold higher than parent drug and likely contribute significantly to therapeutic effect 6