What is the most appropriate benzodiazepine and dosing regimen for occasional short‑term anxiety related to air travel in an adult without hepatic or renal impairment, substance‑use disorder, severe respiratory disease, or pregnancy?

Best Benzodiazepine for Flight-Related Anxiety

For occasional flight anxiety in healthy adults, lorazepam 0.5–1 mg taken 1–2 hours before boarding is the most appropriate choice, offering rapid onset, intermediate duration that matches typical flight times, and minimal hangover effects. 1

Why Lorazepam Is Preferred for Air Travel

• Optimal pharmacokinetic profile: Lorazepam has an onset of 15–20 minutes and duration of 8–15 hours, which aligns perfectly with the time course of most flights—providing coverage from pre-boarding anxiety through landing without excessive next-day sedation. 2

• No active metabolites: Unlike diazepam, lorazepam produces no pharmacologically active metabolites that could accumulate and prolong sedation, making it safer for single-dose situational use. 2

• Intermediate half-life advantage: Short-acting benzodiazepines like triazolam carry greater risks of rebound anxiety and adverse effects, while long-acting agents like diazepam cause marked "hangover" effects that can impair function after landing. 3, 4

Specific Dosing for Air Travel

• Standard adult dose: 0.5–1 mg orally taken 1–2 hours before the anxiety-provoking event (boarding time). 1

• Elderly or debilitated patients: Reduce to 0.25–0.5 mg as a single dose to minimize risks of falls, cognitive decline, and paradoxical agitation. 1

• Maximum frequency: This should be reserved for occasional use only—not for regular weekly flights—to prevent tolerance and dependence. 1

Critical Safety Considerations

• Avoid alcohol: Do not consume alcohol before, during, or immediately after the flight, as alcohol dramatically enhances benzodiazepine effects and increases respiratory depression risk. 4

• Do not combine with other sedatives: Concurrent use of opioids, muscle relaxants, or other CNS depressants can cause potentially fatal respiratory depression. 2

• Paradoxical reactions: Approximately 10% of patients—particularly elderly individuals—may experience paradoxical agitation rather than sedation. 1

• Cognitive impairment: Even single doses can cause psychomotor impairment and amnesia, so patients should not drive or operate machinery after landing until fully alert. 3

Alternative Benzodiazepines (Less Ideal)

• Diazepam: Effective in single doses but has a 20–120 hour half-life with active metabolites, causing prolonged sedation and next-day impairment that interferes with post-flight activities. 2, 3

• Alprazolam: While widely used in the U.S., it is not recommended in the UK for situational anxiety due to higher risk of rebound anxiety and difficult discontinuation. 3, 5

• Oxazepam: Shorter-acting option suitable for episodic anxiety, but may wear off before longer flights conclude. 6

When NOT to Prescribe Benzodiazepines

• Severe respiratory disease: Benzodiazepines can cause respiratory depression and are contraindicated in severe pulmonary insufficiency. 1

• Substance use disorder history: High risk of misuse and dependence development. 2

• Pregnancy: Benzodiazepines cross the placenta and should be avoided. 1

• Severe hepatic impairment: Benzodiazepine clearance is markedly reduced, requiring dose adjustment or avoidance. 2

Non-Pharmacological Alternatives Should Be Offered First

• Medication should be reserved for patients who refuse or cannot access psychological treatment (such as cognitive-behavioral therapy for flight phobia), or for short-term use while awaiting definitive therapy. 1

• Psychological interventions have more durable effects without the risks of dependence, cognitive impairment, or paradoxical reactions. 3

Common Prescribing Pitfalls to Avoid

• Do not prescribe standing doses: A single pre-flight dose is appropriate; do not prescribe "0.5 mg three times daily" for travel days, as this increases adverse effects without additional benefit. 1

• Do not prescribe for chronic use: Even for frequent flyers, benzodiazepines should not be used regularly due to rapid tolerance development (within 2–4 weeks) and dependence risk. 3, 6

• Do not exceed 2 mg total: Higher doses provide no additional anxiolytic benefit but markedly increase sedation, amnesia, and respiratory depression risk. 1

• Warn about memory impairment: Patients may not remember portions of their flight or immediate post-landing period due to benzodiazepine-induced anterograde amnesia. 3