Management of Treatment-Resistant Anxiety

Assessment and Optimization of Current Regimen

The American Academy of Family Physicians recommends that lorazepam 1 mg twice daily represents chronic benzodiazepine use, which carries significant risks including tolerance, addiction, cognitive impairment, and paradoxical agitation in approximately 10% of patients 2, 3
The American Academy of Family Physicians suggests that regular benzodiazepine use is not recommended for routine anxiety management and should be reserved for short-term crisis intervention 2
The National Comprehensive Cancer Network recommends that pregabalin has robust evidence for anxiety disorders and neuropathic components of anxiety 4

The National Comprehensive Cancer Network suggests starting pregabalin 50 mg three times daily, increase to 100 mg three times daily after one week, with adjustment for renal insufficiency 4
The National Comprehensive Cancer Network recommends starting gabapentin 100-300 mg nightly, titrate to 900-3600 mg daily in 2-3 divided doses, with slower titration for elderly or medically frail 4

The American Academy of Family Physicians recommends beginning a gradual taper of lorazepam over 10-14 weeks to avoid withdrawal symptoms and assess true baseline anxiety without benzodiazepine tolerance 2
The American Academy of Family Physicians suggests reducing lorazepam by 0.25 mg every 1-2 weeks, slower if withdrawal symptoms emerge 2

The American Academy of Family Physicians recommends not abruptly discontinuing duloxetine or lorazepam, as both require gradual tapering over 10-14 days minimum to prevent withdrawal symptoms 1, 2
The American Academy of Family Physicians suggests not continuing benzodiazepines long-term, as tolerance and dependence undermine treatment efficacy 2