Xanax or Ativan: Which Is Better for Anxiety?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Benzodiazepines are one of the most commonly taken psychotropic drugs, often used for anxiety. Prolonged use of them is a widespread phenomenon in medical practice, yet it may surprise you to know that these medications are really only meant to be used short term. Both alprazolam (Xanax) and lorazepam (Ativan) are considered short-acting benzodiazepines and when used for the right reasons, are quite effective.

Many of you wonder if they’re the same, which is better, and what’s the difference between the two.

What are they used for?

Alprazolam (Xanax) is used for the treatment of anxiety disorders, short-term relief of anxiety symptoms, anxiety associated with depression, and panic disorder with or without agoraphobia.

Lorazepam (Ativan) is approved for management of anxiety disorders, short-term (four months or less) relief of anxiety symptoms, anxiety associated with depression, and anxiety- or stress-associated insomnia.

An important distinction here is Xanax is approved for use in panic disorder; Ativan is not.

Which one is better for anxiety?

Numerous randomized trials have found both alprazolam (in immediate- and extended-release formulations) and lorazepam work well for panic disorder. Benzodiazepines initiate anti-panic effects very rapidly, within the first week of treatment. That’s why they’re so popular. However, of the benzodiazepines, only alprazolam and the longer-acting benzodiazepine, clonazepam (Klonopin), are approved by the FDA for the treatment of panic disorder—not lorazepam.

Longer-term anxiety meds, like selective serotonin re-uptake inhibitors (SSRIs), take a few weeks to work. This may be a distinct advantage of short-acting benzodiazepines in severely symptomatic and impaired patients who require rapid relief.

What are the forms and dosages?

There are some differences here.

Ativan is available as 0.5 mg, 1 mg and 2 mg tablets, as is the generic, lorazepam. Lorazepam is used for anxiety disorder as well as insomnia due to anxiety or stress. For anxiety disorder, lorazepam 1 mg to 2 mg is used daily in two to three divided doses throughout the day. For insomnia, lorazepam is dosed at 2 mg to 4 mg at bedtime.

Unlike lorazepam, alprazolam (Xanax) comes in an immediate- and an extended-release (XR) form. Immediate-release alprazolam comes in 0.25 mg to 2 mg tablets, as does brand-name Xanax. The usual dose of immediate-release alprazolam is 0.25 mg to 0.5 mg every eight hours as needed. Extended-release alprazolam comes in 0.5 mg to 3 mg tablets. Extended-release alprazolam or Xanax XR is dosed at 0.5 mg to 1 mg twice a day.

How fast do they work and how long do they last?

There are some subtle differences between the two here too. This is important to remember if you are using them before getting on a plane, having a root canal, or getting into an MRI scanner.

With alprazolam (Xanax), the onset of action for BOTH the immediate-release and extended-release formulations is one hour. Regular alprazolam will work for about five hours. Extended-release alprazolam will work for about 11 hours.

Lorazepam (Ativan) has a more rapid onset of action—30 to 60 minutes—and may last up to eight hours.

Both are cleared by the liver, so they will last longer in folks with liver disease. Interestingly, alprazolam lasts longer in Asians (25% longer half-life compared to Caucasians), obese patients and the elderly.

What are the side effects of alprazolam vs. lorazepam?

Side effects of these two drugs are pretty much the same. Most come from their actions on the nervous system. They include cognitive dysfunction, depression, dizziness, drowsiness, dysarthria (a motor speech disorder), fatigue, irritability, memory impairment and sedation.

The big downside, psychological dependence

Alprazolam and lorazepam carry the stigma of higher potential for abuse compared to a longer-acting benzodiazepine like clonazepam because they have a short half-life and a rapid onset of action. That means they may require more pill taking (three to four times a day) to alleviate anxiety, thus enhancing the potential for abuse.

Long-term use of both alprazolam and lorazepam carries the same risk of the development of physical and psychological dependence and withdrawal symptoms when discontinuing them. Studies show that when either lorazepam or alprazolam are used for more than one month, dependence will occur in 47% of those taking them. That’s high, right?

The same warnings apply for both drugs here. Don’t stop either drug abruptly if you’ve been taking it for more than two weeks. Abrupt discontinuation should be avoided—instead lower your daily dose by 0.5 mg every three days.

In addition, both shouldn’t really be used long term. Treatment for more than four months should be re-evaluated to determine the patient’s continued need for the drug. Really, short-term.

What about cost?

Both Xanax and Ativan are quite expensive based on cash price, running upwards of several hundred dollars for 60 tablets. But remember, your generics will always be cheaper than your brand-name drugs. For 60 1 mg tablets, alprazolam costs around $20 and lorazepam costs around $40.  

Another option for lowering the price of these medications may be pill splitting. Xanax and Ativan tablets are both scored, so pill splitting is an option. However, the extended-release tablets should never be broken or split.

Dr O.

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