How to manage primary care patients with severe anxiety who have failed hydroxyzine and Buspar (buspirone) along with Lexapro (escitalopram) and report that lorazepam (Ativan) is the only medication that has provided relief in the past?

From the Guidelines

When managing patients requesting lorazepam for anxiety, I would prioritize a comprehensive approach that considers their previous treatments and the potential risks and benefits of benzodiazepines, and thus, I would consider prescribing lorazepam at the lowest effective dose as needed, while simultaneously optimizing their current treatment regimen and exploring alternative therapies. Given the patient's history of trying hydroxyzine, buspar, and lexapro without adequate relief, and their report of previous benefit from lorazepam, it's essential to weigh the potential benefits of a limited trial of lorazepam against the risks of dependence and other side effects 1. The patient's preference for psychological treatments, as noted in the study by Lang (2005) and Wetherell et al. (2004), should also be taken into account, and integrated primary care (IPC) could be a viable solution to increase the use of psychological treatments for anxiety in primary care settings 1. Key considerations in managing the patient's anxiety include:

• Optimizing their SSRI dosing, ensuring they've reached therapeutic doses of Lexapro, typically 10-20mg daily
• Considering adding cognitive behavioral therapy to their treatment plan
• Prescribing lorazepam at the lowest effective dose, typically starting at 0.5mg, to be taken as needed, with clear limits on quantity and duration
• Scheduling regular follow-ups to monitor for effectiveness, side effects, and signs of dependence
• Exploring alternative medications like SNRIs, mirtazapine, or pregabalin if appropriate, as benzodiazepines are not optimal for long-term use due to the risk of tolerance, dependence, and cognitive impairment 1.

From the FDA Drug Label

Lorazepam Oral Concentrate USP is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms. The physician should periodically reassess the usefulness of the drug for the individual patient. Lorazepam Oral Concentrate is a prescription medicine used: to treat anxiety disorders for the short-term relief of the symptoms of anxiety or anxiety that can happen with symptoms of depression It is not known if lorazepam oral concentrate is safe and effective for use for longer than 4 months.

The patient has already tried other medications such as hydroxyzine, buspar, and lexapro, and is still experiencing extreme anxiety. Lorazepam may be considered for short-term relief of anxiety symptoms. However, it is crucial to weigh the benefits and risks, considering the patient's history and the potential for abuse, misuse, and addiction 2, 3.

• The patient should be closely monitored for signs of dependence or withdrawal reactions.
• The physician should periodically reassess the usefulness of the drug for the individual patient.
• Alternative treatment options should be explored, and the patient should be educated about the risks and benefits of lorazepam treatment 3.

From the Research

Handling Primary Care Patients with Anxiety

• When dealing with primary care patients who want a prescription for anxiety, such as lorazepam, it's essential to consider alternative treatments and therapies that have shown efficacy in reducing anxiety symptoms 4, 5, 6.
• Buspirone, an azapirone derivative, has been found to have anxiolytic properties similar to benzodiazepines, but with increased safety and lack of dependency-producing aspects 7.
• Nonpharmaceutical interventions, such as music, cognitive behavioral therapy (CBT), relaxation, massage, acupuncture/acupressure, hypnosis, and natural sounds, have been shown to be effective in reducing anxiety in over 70% of experiments 6.
• Combined therapy, including CBT and pharmacotherapy (SSRI), has been found to be more effective than either treatment alone in treating panic disorder with or without agoraphobia 8.

Alternative Treatments for Anxiety

• Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have been found to have broad-spectrum antidepressant and antianxiety effects, and decrease general psychological distress 4, 5.
• MBSR has been beneficial for general psychological health and stress management in those with medical and psychiatric illness, as well as in healthy individuals 4.
• Zen meditation has been found to have a role in pain management and reducing anxiety symptoms 4.

Considerations for Prescribing Lorazepam

• Lorazepam is a benzodiazepine with potential for dependency and abuse, and its use should be carefully considered and monitored 7.
• Patients who demand immediate gratification or relief may not be suitable for buspirone, which has a slower onset of action 7.
• A thorough evaluation of the patient's medical history, current symptoms, and treatment goals should be conducted before prescribing any medication, including lorazepam 8.