Acute anxiety

First line treatment is non-pharmacological measures.

2mg 3 times daily increased if necessary to 15-30mg daily in divided doses.

Prescribers should be aware of recent increases in propranolol overdoses and consider patients risk factors before prescribing.

10-40mg once daily, can be increased if necessary to 3-4 times a day.

Prescribing Notes:

Patient self-help guides on anxiety problems are available at the Mood Café website. Consider relaxation, self-help cognitive behavioural therapy (Living Life to the Full website) and reduced caffeine intake.
Benzodiazepines are indicated for the short-term relief (2-4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress. The use of benzodiazepines to treat short-term “mild” anxiety is inappropriate and unsuitable. Anxiety is a normal response to stress.
Treatment should be limited to the lowest possible dose for the shortest possible time.
Use with caution if patient has a history of alcohol or drug misuse.
Diazepam has a long duration of action and rapid onset. It is the recommended daytime anxiolytic and is used as premedication before surgery and other procedures.
Beta-blockers (e.g. propranolol) can be useful for reducing autonomic symptoms, such as palpitations and tremor in performance anxiety (e.g. public speaking or a musical performance).
Prescribers should be aware of the risk of propranolol in overdose, which can be potentially toxic and lead to seizures and death.
Propranolol is a non-cardioselective beta-blocker and is contraindicated in patients with asthma.
Benzodiazepines should be avoided in older patients if possible. Older patients can become ataxic, confused and are at increased risk of falling and injuring themselves.
Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. For further advice see MHRA Drug Safety Update, March 2020.
Benzodiazepines should not be used as sole treatment for chronic anxiety.
Patients who have been on a benzodiazepine for many years can be switched to diazepam and the diazepam then be slowly withdrawn (see BNF withdrawal protocol).
Lorazepam acts for a shorter period and does not accumulate with repeated doses but has greater potential for withdrawal phenomena, dependence and abuse. It can be useful in patients with impaired liver function and in the elderly.
General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.

History Notes

09/04/2024

Addition of link to general notes on prescribing in pregnancy, ERWG May 24.

27/10/2022

East Region Formulary content agreed.

First line treatment is non-pharmacological measures.

Dose as per specialist.

Prescribing Notes:

Clinicians should exercise caution when prescribing benzodiazepines for children and adolescents. The response can be unpredictable, patients may become disinhibited.
Patient self-help guides on anxiety problems are available at the Mood Café website. Consider relaxation, self-help cognitive behavioural therapy (Living Life to the Full website) and reduced caffeine intake.
Benzodiazepines are indicated for the short-term relief (2-4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress. The use of benzodiazepines to treat short-term “mild” anxiety is inappropriate and unsuitable. Anxiety is a normal response to stress.
Treatment should be limited to the lowest possible dose for the shortest possible time.
Diazepam has a long duration of action and rapid onset. It is the recommended daytime anxiolytic and is used as premedication before surgery and other procedures.
Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. For further advice see MHRA Drug Safety Update, March 2020.

History Notes

15/01/2024

East Region Formulary content agreed.