What is the initial dose of buspirone for an adult with generalized anxiety, and how should it be adjusted for elderly patients or those with hepatic impairment?

Buspirone Starting Dose

Start buspirone at 5 mg twice daily (BID) for most adults with generalized anxiety disorder, with gradual titration by 5 mg increments every 2-3 days to reach a therapeutic range of 15-30 mg/day. 1

Standard Adult Dosing

• Initial dose: 5 mg twice daily is the most commonly recommended starting point for adult patients 1
• An alternative starting approach of 7.5 mg twice daily exists, though the lower 5 mg BID dose is preferred in guidelines 1
• Titrate gradually by 5 mg increments every 2-3 days as tolerated 1
• Target therapeutic dose is 15-30 mg/day, with a maximum of 60 mg/day (20 mg three times daily) 1

Elderly and Special Populations

• Elderly or debilitated patients should start at 2.5-5 mg twice daily with more gradual titration, as this population is more sensitive to medication effects 1
• For patients with hepatic impairment, use the lower end of the dosing range and titrate cautiously, though specific dosing adjustments are not well-established in guidelines 1

Critical Timing Considerations

• Buspirone requires 2-4 weeks to become effective, which is a crucial counseling point for patient compliance 2
• A full therapeutic trial requires 4-8 weeks before determining efficacy 1
• This delayed onset differs markedly from benzodiazepines and necessitates patient education to maintain adherence 3

Dosing Schedule Options

• Both BID and TID regimens are effective, with similar safety profiles 4
• BID dosing (15 mg twice daily) may offer better convenience and compliance compared to TID dosing (10 mg three times daily) without compromising safety 4
• The only notable difference is a slightly higher incidence of palpitations with BID dosing (5% vs 1%) 4

Common Pitfalls to Avoid

• Do not expect immediate anxiolytic effects—the 1-2 week lag time requires proactive patient counseling to prevent premature discontinuation 3
• Buspirone is useful only in patients with mild to moderate agitation; it is not appropriate for acute anxiety management 2
• Unlike benzodiazepines, buspirone lacks sedative, anticonvulsant, and muscle relaxant properties, making it "anxioselective" 3
• The medication causes minimal sedation and does not impair psychomotor function, making it particularly useful when daytime alertness is important 3, 5