In a patient with stable asthma who is initiating a selective serotonin reuptake inhibitor, which short‑acting PRN (as‑needed) anxiolytic is appropriate for panic attacks, and is buspirone (Buspar) appropriate?

Buspirone Is Not Appropriate for PRN Use in Panic Attacks

You are correct—buspirone (Buspar) should never be used as a PRN (as-needed) agent for panic attacks, and I apologize for any prior suggestion to the contrary. Buspirone requires continuous daily dosing for 2–4 weeks to achieve anxiolytic effects and has no role in acute panic management 1, 2.

---

Why Buspirone Cannot Be Used PRN

Mechanism and Onset of Action

• Buspirone is a 5-HT1A partial agonist that works through gradual downregulation of serotonin autoreceptors, a process requiring weeks of continuous daily administration to produce therapeutic benefit 1.
• The drug demonstrates a slow and gradual onset of anxiety relief, making it fundamentally incompatible with the immediate symptom control required during acute panic attacks 1.
• Studies in panic disorder have been inconclusive, and buspirone is not recommended for routine treatment of panic disorder at all—let alone for PRN use 1.

Clinical Evidence Against PRN Use

• Buspirone is indicated only for chronic anxiety and generalized anxiety disorder with continuous daily dosing 2.
• The drug is most appropriate for patients who do not demand immediate gratification or the rapid relief associated with benzodiazepines 1.
• There is no evidence supporting PRN administration of buspirone for any anxiety condition 1, 2.

---

Appropriate PRN Anxiolytic for Panic Attacks in Stable Asthma

For a patient with stable asthma initiating an SSRI who requires PRN relief of panic attacks, a short-acting benzodiazepine such as lorazepam is the evidence-based choice.

Recommended Agent: Lorazepam

• Lorazepam is a short-acting benzodiazepine anxiolytic that provides rapid relief of acute panic symptoms within minutes 3.
• Typical PRN dosing: 0.5–1 mg orally at the onset of panic symptoms, which can be repeated after 1–2 hours if needed (maximum 2–4 mg/day in divided doses) 3.
• Lorazepam has a half-life of 10–20 hours, allowing effective acute control without excessive accumulation 3.

Safety in Asthma

• Short-acting benzodiazepines like lorazepam are not contraindicated in stable asthma 3.
• The guideline warning against chemical restraint in asthma specifically refers to anticholinergic antipsychotic agents (e.g., chlorpromazine) in severe asthma, not to benzodiazepines in stable disease 3.
• Benzodiazepines do carry a risk of paradoxical agitation in some patients, which should be assessed during initial psychiatric evaluation 3.

Critical Safety Considerations

• Never use benzodiazepines during acute asthma exacerbations—sedatives of any kind are absolutely contraindicated in acute respiratory distress because they can precipitate respiratory failure 3.
• Benzodiazepines are appropriate only for stable asthma between exacerbations 3.
• The SSRI will require 6–12 weeks to achieve full anxiolytic effect, during which time PRN lorazepam bridges the gap 3.

---

Bridging Strategy While SSRI Takes Effect

Timeline

• SSRIs demonstrate statistically significant improvement by week 2 but require 6–12 weeks for maximal clinical benefit 3.
• During this titration period, PRN lorazepam provides acute panic relief while the SSRI builds therapeutic effect 3.

Transition Plan

• As the SSRI reaches therapeutic levels (typically 8–12 weeks), taper and discontinue the benzodiazepine to avoid long-term dependence 3.
• Monitor for suicidal ideation during SSRI initiation, especially in the first months and after dose adjustments 3.
• Close follow-up is essential, with parental oversight of medication regimens in children and adolescents 3.

---

Why Other Options Are Inappropriate

Buspirone

• Requires continuous daily dosing for weeks to achieve effect 1, 2.
• Not effective for panic disorder 1.
• Cannot provide acute symptom relief 1.

Hydroxyzine or Diphenhydramine

• Antihistamines have been used for chemical restraint but carry a risk of paradoxical increase in rage 3.
• They are not first-line for panic attacks and lack robust evidence in this indication 3.

PRN Use of Chemical Restraints

• Guideline evidence explicitly states that PRN use of chemical restraints is prohibited in psychiatric settings, reinforcing that anxiolytics must be used in a planned, monitored fashion rather than as unscheduled emergency interventions 3.

---

Common Pitfalls to Avoid

• Never suggest buspirone for PRN use—it has no role in acute anxiety management 1, 2.
• Never use sedatives during acute asthma exacerbations—this is a life-threatening error 3.
• Do not delay SSRI initiation while relying solely on benzodiazepines; the SSRI is the definitive treatment 3.
• Monitor for benzodiazepine dependence—plan discontinuation once the SSRI is fully effective 3.