PRN Medication for Panic Attack in Geriatric Patient on Buspar and Cymbalta
For this geriatric patient experiencing panic attacks while on buspirone and duloxetine, lorazepam 0.25-0.5mg orally PRN is the recommended non-narcotic option, with a maximum of 2mg in 24 hours. 1
First-Line PRN Recommendation
Lorazepam is the preferred benzodiazepine for PRN use in elderly patients due to its short half-life, lack of active metabolites, and predictable pharmacokinetics. 1
The recommended starting dose is 0.25-0.5mg orally four times a day as required, with a maximum dose of 2mg in 24 hours for elderly patients with anxiety. 1
Start at the lower end (0.25mg) in frail elderly patients to minimize fall risk and oversedation. 1
Why Lorazepam Over Other Options
Among short half-life benzodiazepines, lorazepam has more predictable pharmacokinetics compared to alprazolam, which may cause more intense dependence, rebound symptoms, and memory impairment. 2
Long half-life benzodiazepines should be avoided in older patients due to cumulative toxicity and prolonged sedation. 1, 2
SSRIs (already on duloxetine) and buspirone (already on Buspar) have delayed onset of action and are not suitable for acute panic attacks requiring PRN relief. 3
Critical Safety Considerations and Monitoring
Approximately 10% of elderly patients experience paradoxical agitation with benzodiazepines, so monitor closely after initial doses. 1
Benzodiazepines significantly increase fall risk in the elderly—counsel patient on fall precautions and avoid use before ambulation. 1
Regular use can lead to tolerance, addiction, depression, and cognitive impairment, so emphasize PRN use only for acute panic episodes, not daily scheduled dosing. 1
Monitor for oversedation given the patient is already on duloxetine, which can have sedating effects. 1
Why Not Other Options
Buspirone (already prescribed) is not effective for panic disorder or acute panic attacks—studies have been inconclusive, and it is not recommended for routine treatment of panic disorder. 4
Antipsychotics like quetiapine or olanzapine are not appropriate for panic attacks in non-psychotic, non-agitated patients and carry black box warnings for increased mortality in elderly patients with dementia. 1, 5
Beta blockers lack sufficient evidence in elderly populations for anxiety treatment. 5
Drug Interaction Considerations
No significant pharmacokinetic interactions exist between lorazepam and buspirone or duloxetine, though additive sedation is possible—use lowest effective dose. 1
The patient's current regimen (buspirone 5mg BID and duloxetine 30mg) represents appropriate long-term anxiety management, with lorazepam serving as acute rescue medication only. 3
Patient Education Points
Use lorazepam only during actual panic attacks, not prophylactically.
Take while seated or lying down due to fall risk.
Avoid alcohol completely while using this medication.
Do not drive or operate machinery after taking lorazepam.
Contact provider if needing more than 2-3 doses per week, as this suggests inadequate baseline anxiety control requiring adjustment of standing medications. 3