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Optimizing benzodiazepine treatment of anxiety disorders

Current Psychiatry. 2023 June;22(6):22-33,39 | doi: 10.12788/cp.0365
June 1, 2023|Current Psychiatry
Jeffrey R. Strawn, MD;Julia Stimpfl, MD
Author and Disclosure Information

Jeffrey R. Strawn, MD
Professor of Psychiatry, Pediatrics, and Clinical Pharmacology Director, Anxiety Disorders Research Program

Julia Stimpfl, MD
PGY-2 General Psychiatry Resident

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Department of Psychiatry and Behavioral Neuroscience University of Cincinnati College of Medicine Cincinnati, Ohio

Disclosures
Dr. Strawn has received research support from Abbvie, the National Center for Advancing Translational Sciences, the National Institutes of Health (NIH), and the Patient-Centered Outcomes Research Institute. He has served as a consultant for Cerevel, the FDA, IntraCellular Therapies, Lundbeck, and Otsuka. He receives royalties from Springer Publishing and UpToDate and received material support from Myriad. He also received honoraria from the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, Medscape Live, and Neuroscience Education Institute. Dr. Strawn is Current Psychiatry’s Section Editor, Child and Adolescent Psychiatry. Dr. Stimpfl reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. Views expressed within this article represent those of the authors and are not intended to represent the position of the NIH, the National Institute of Mental Health, or the Department of Health and Human Services.

Acknowledgments
This work was supported by the Yung Family Foundation (Dr. Strawn).

Understanding the pharmacology of these agents can help guide medication selection and dosing.

The properties of individual benzodiazepines should also be considered when selecting a benzodiazepine treatment. If circumstances necessitate rapid symptom relief, a lipophilic benzodiazepine, such as diazepam, may be preferred for quick onset and offset of action. Onset of action may also be hastened by taking the benzodiazepine without food; conversely, if peak adverse effects are problematic, concurrent consumption of a high-fat meal may help decrease peak concentration and prolonging absorption. In other circumstances, such as if sustained anxiolysis is desired, a clinician may opt for a less lipophilic benzodiazepine, such as clonazepam. Finally, in terms of general treatment response, benzodiazepines separate from placebo in the first week of treatment, which supports the idea they may be useful during the introduction of other medications (eg, SSRIs) that take a longer time to achieve clinical effect.

Bottom Line

The pharmacokinetics of benzodiazepines are intimately linked with the onset of action and duration of clinical effect and vary based on individual absorption and distribution/redistribution. Benzodiazepines’ clinical profile derives from their pharmacokinetic differences and is influenced by many factors, including age, body weight, concomitant medication use, smoking status, and hepatic or renal disease. Consider these factors to individualize the approach to using benzodiazepines and optimize tolerability and efficacy.

Related Resources

Drug Brand Names

Alprazolam • Xanax
Chlordiazepoxide • Librium
Clobazam • Onfi
Clonazepam • Klonopin
Clorazepate • Gen-Xene
Diazepam • Valium
Diltiazem • Cardizem
Fluvoxamine • Luvox
Ganaxolone • Ztalmy
Ketoconazole • Nizoral
Lorazepam • Ativan
Midazolam • Versed
Temazepam • Restoril
Triazolam • Halcion
Verapamil • Calan

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