What are the as-needed medication options for anxiety?

As-Needed Medications for Anxiety

Benzodiazepines are the only FDA-approved as-needed medications for acute anxiety relief, with alprazolam specifically indicated for short-term management of anxiety symptoms and panic disorder. 1

FDA-Approved PRN Options

Benzodiazepines (Primary PRN Agents)

Alprazolam is FDA-indicated for anxiety disorder management and short-term relief of anxiety symptoms, as well as panic disorder treatment. 1 The FDA label specifies it addresses generalized anxiety disorder characterized by unrealistic or excessive worry about multiple life circumstances. 1

Clinical use parameters:

• For episodic anxiety: Short-acting benzodiazepines (oxazepam, lorazepam, alprazolam) are preferred for intermittent use when anxiety occurs in discrete episodes. 2
• For acute stress reactions: Diazepam given in single doses or very short courses (1-7 days) is the drug of choice. 3
• Duration limits: Prescriptions should be limited to a few days, occasional/intermittent use, or courses not exceeding 2-4 weeks maximum. 3, 4

Second-Line PRN Considerations

Canadian guidelines recommend benzodiazepines (alprazolam, bromazepam, clonazepam) as second-line agents specifically for rapid anxiety relief when first-line SSRIs/SNRIs have failed. 5

Critical Warnings and Limitations

Benzodiazepines should NOT be used for routine anxiety management due to risks of dependence, tolerance, and withdrawal. 4, 6 They are reserved exclusively for:

• Acute stress reactions 3
• Episodic anxiety requiring rapid relief 3
• Initial treatment while waiting for SSRIs/SNRIs to take effect (2-6 weeks) 7
• Severe panic attacks as bridging therapy 3

Concurrent opioid use is contraindicated - avoid prescribing benzodiazepines to patients on opioids due to fatal respiratory depression risk. 8 If both are prescribed, taper opioids first as benzodiazepine withdrawal carries greater risks including seizures and delirium tremens. 8

What NOT to Use PRN

Beta-blockers (atenolol, propranolol) have negative evidence for anxiety disorders and are not recommended. 7 They have only limited adjunctive use for performance anxiety. 9

Antipsychotics (quetiapine) have negative evidence for social anxiety disorder. 5

The Preferred Alternative: Scheduled SSRIs/SNRIs

Rather than PRN medications, scheduled daily SSRIs or SNRIs are the evidence-based first-line treatment for all anxiety disorders. 7, 4, 6

• Escitalopram (10-20 mg daily) or sertraline (50-200 mg daily) are top-tier first-line agents with the most favorable profiles. 7
• Response begins at week 2, becomes clinically significant by week 6, and reaches maximum benefit by week 12. 7
• These should be combined with cognitive behavioral therapy for optimal outcomes. 7, 5

Practical Algorithm for PRN Anxiety Medication

1. First, ensure patient is on scheduled SSRI/SNRI - PRN benzodiazepines should only supplement, not replace, first-line treatment. 7, 4

2. If acute relief needed while starting SSRI/SNRI: Prescribe alprazolam or lorazepam for 1-2 weeks maximum as bridging therapy. 3

3. For episodic anxiety only: Consider alprazolam or lorazepam PRN, limited to 2-4 week supply maximum. 3, 2

4. Avoid in patients with: History of substance abuse, concurrent opioid use, elderly patients (increased fall risk), or need for long-term management. 8, 3

5. Taper gradually when discontinuing - abrupt cessation causes withdrawal seizures, rebound anxiety, and rarely death. 8 Use 25% dose reduction every 1-2 weeks. 8