What are good non-controlled medications for PRN (as needed) management of anxiety?

Non-Controlled PRN Anxiety Medications

Hydroxyzine is the best non-controlled medication for PRN anxiety management, particularly when sedation is acceptable or in patients with substance abuse history. 1

First-Line Non-Controlled PRN Option

• Hydroxyzine (antihistamine) is specifically recommended as a non-addictive alternative to benzodiazepines for PRN anxiety, particularly useful when sedation is desired or in patients with a history of substance abuse 1
• Typical dosing is 25-50 mg orally every 6 hours as needed, though specific PRN dosing should be individualized based on patient response and tolerability 1

Second-Line Options for Situational Anxiety

• Beta-blockers (propranolol 10-40 mg PRN) can help with physical symptoms of anxiety including tremor, tachycardia, and sweating, but are best reserved for situational anxiety with prominent somatic symptoms rather than primary anxiety treatment 1
• Beta-blockers are not recommended as primary treatment for social anxiety disorder based on negative evidence 1
• Caution is required in patients with asthma, diabetes, or certain cardiac conditions when using beta-blockers 1

Important Limitations of Other Non-Controlled Medications

• Buspirone is NOT appropriate for PRN use because it requires 2-4 weeks to become fully effective and must be dosed regularly (5 mg twice daily initially, maximum 20 mg three times daily) 1, 2, 3
• Buspirone works as a 5-HT1A partial agonist and lacks the immediate anxiolytic effect needed for PRN management 3, 4
• Gabapentin can be considered when first-line treatments fail, particularly for patients with comorbid pain conditions, but also requires regular dosing rather than PRN use 1

Critical Pitfall to Avoid

• Do not prescribe SSRIs or SNRIs for PRN anxiety - these medications (escitalopram, sertraline, venlafaxine, duloxetine) require daily dosing for 2-12 weeks to achieve therapeutic effect and are completely ineffective when used as needed 5, 2
• Even though SSRIs/SNRIs are first-line for chronic anxiety disorders, they have no role in PRN management 5

When Non-Controlled Options Are Insufficient

• If hydroxyzine or beta-blockers prove inadequate for PRN anxiety control, consider transitioning to scheduled daily SSRI/SNRI therapy (escitalopram 10-20 mg daily or sertraline 50-200 mg daily) rather than escalating to controlled substances 5
• Combining scheduled SSRI/SNRI with cognitive behavioral therapy provides superior outcomes compared to medication alone for long-term anxiety management 5, 2