Ativan vs. Xanax

The decision of whether to prescribe Ativan vs. Xanax is one I face frequently, but really the more important decision is whether using any short acting benzodiazepine is the appropriate choice. As a family doctor I am the first physician many patients see when they are faced with acute anxiety, panic disorder or phobias for which a short acting benzodiazepine is often the appropriate therapy. Ativan (lorazepam) and Xanax (alprazolam)  are the most commonly used medications in this class for these indications, although Klonapin, clonazepam is also used in some settings.  I tend to feel that both Ativan and Xanax are somewhat faster acting and possibly more effective for acute anxiety than Klonapin, so tend to use these for patients where I anticipate infrequent or occasional use, and use Klonapin more often when I anticipate the need for longer term use or more frequent dosing.  The faster onset of action and somewhat shorter serum half-life of Ativan and Xanax make them have a higher abuse potential and addiction potential, so I often try to use Klonapin in these circumstances.

The bigger question is when to use Ativan and when to use Xanax.  Actually this is really splitting hairs, as these meds are very similar. Let’s look at the details of the similarities and differences in Ativan vs. Xanax.

Ativan Xanax
Serum Half Life 14 hours 11.2 hours
Potency Starting dose 0.5 mg Starting dose 0.25 mg
Onset of Action Rapid Rapid
Addiction Potential High High
Side Effects Sedation, abuse potential, addiction/dependency, Nearly identical to Ativan
Cost ( 0.5 mg #30  $14.99 0.25 mg  #30  $11.99
FDA approved indications Anxiety, insomnia short term Rx, status epilepticus, chemotherapy induced nausea, post-operative sedation Anxiety, panic disorder

As you can tell from the above comparisons, Ativan and Xanax are much more alike than they are different. Both are fast acting, short half-life benzodiazapines with indications for anxiety.  Although Ativan lacks an FDA indication for panic disorder it is commonly used off label for panic. Ativan has specific indications for chemotherapy induced nausea, status epilepticus and post-operative sedation and to my knowledge Xanax is not often used for these niche indications.

For the primary indication that both Ativan and Xanax are prescribed, various types of anxiety disorder, the choice is often based on the prescribing physician’s personal preference.  I tend to use Xanax a bit more because I have more experience with Xanax, but other physicians may choose Ativan in the same circumstances.  I tend to choose Ativan when the primary problem facing a patient is anxiety leading to insomnia, and tend to choose Xanax when depression is a major factor and I’m adding an as needed drug to an antidepressant. I tend to choose Klonapin when I suspect a patient may need to take the medication regularly for more than a few days because I have found that patients have less trouble tapering an stopping Klonapin than either Ativan of Xanax. The incidence and spectrum of Ativan side effects, Xanax side effects and Klonapin side effects are similar enough that side effects are not a major factor in choosing a medication.

All benzodiazapines are best used for short term management of anxiety and panic disorder.  For ongoing treatment medications like the selective serotonin reuptake inhibitors are best used to prevent panic attacks and keep anxiety at bay, using drugs like Ativan and Xanax for acute episodes of anxiety and panic.


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