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Ativan vs Xanax: What's the difference?

With anxiety rates on the rise in the United States and an estimated 40 million American adults suffering from anxiety, prescriptions of anti-anxiety medications like Ativan and Xanax are on the rise. Anxiety is the most common mental health in the country, as nearly 20 percent of the population struggles with the condition, but less than 40 percent of those suffering receive treatment. Over 56 million prescriptions are written for Xanax and Ativan combined each year, making them some of the most commonly prescribed drugs in the country. While the drugs are similar in many ways, they also have some key differences.

Drug Class

Both Xanax and Ativan belong to a class of drugs called benzodiazepines (benzos) , which also includes other anti-anxiety medications like Klonopin and Valium. Both drugs are tranquilizers that are also referred to as sedative-hypnotics or anxiolytics.  Xanax comes in the form of oral tablets of varying strengths and is available in immediate-release and extended-release formulas, while Ativan is available as both an oral tablet and an injection, each of which are used to treat different conditions.

Conditions Treated

Ativan is approved by the U.S. Food and Drug Administration (FDA) for the treatment of three conditions: anxiety, insomnia, and seizures. The oral form of Ativan is used to treat anxiety and insomnia, while the intravenous form of the drug is used to treat severe seizures called status epilepticus. Xanax is FDA-approved for the treatment of anxiety disorders, short-term relief of anxiety symptoms, anxiety associated with depression, and panic disorder.

Anxiety

When the body experiences stress and we feel fearful or apprehensive about what is to come, anxiety is our natural response. Everyone experiences anxiety from time to time about one thing or another, but anxiety disorders occur when anxiety becomes a problem because the feelings are extreme, last longer than six months, and interfere with your life. There are eight main types of anxiety disorders, including:

  • Generalized anxiety disorder
  • Panic disorder
  • Phobia
  • Social anxiety disorder
  • Obsessive-compulsive disorder
  • Separation anxiety disorder
  • Illness anxiety disorder
  • Post-traumatic stress disorder.

Patients experiencing anxiety may experience symptoms like an increased heart rate, rapid breathing, restlessness, trouble concentrating, and difficulty falling asleep. A more acute form of anxiety, called an anxiety attack, has symptoms that include feeling faint or dizzy, shortness of breath, dry mouth, sweating, chills or hot flashes, apprehension and worry, restlessness, distress, fear, numbness or tingling

How it Works

Both Xanax and Ativan work on a neurotransmitter in the brain called gamma-aminobutyric acid (GABA), which is partially responsible for the regulation of sleep and controls feelings of relaxation and anxiety.  When a patient takes Ativan or Xanax, the medication bonds to GABA receptors in the brain, preventing the GABA from binding to the receptors. This reduces neuron activity by slowing down the central nervous system, causing a reduction in feelings of anxiety, fear, and terror. 

Duration

Both Xanax and Ativan are fast-acting medications that are designed to work quickly and leave the body in a relatively short amount of time due to their powerful effects. Both the immediate-release and extended-release versions of Xanax start working in about an hour. The immediate-release form of Xanax lasts for about five hours, while the extended-release form of the drug will continue working for about eleven hours. Ativan starts working immediately and reaches its full effect in approximately an hour to an hour and a half. The effects of the medication typically last around six to eight hours, so it may need to be taken several times per day to control anxiety symptoms, as may Xanax. 

Benefits

Both Xanax and Ativan have many benefits despite also having some considerable drawbacks to their use. Both medications are capable of producing anti-anxiety effects very quickly and generally provide noticeable results and relief within the first week of treatment. Slower-acting anti-anxiety medications, such as Lexapro and Zoloft, may take several weeks for patients to experience relief, so use of Xanax or Ativan is helpful in providing immediate relief for patients who are really struggling to manage their symptoms. Both medications can be prescribed in conjunction with a slower-acting antidepressant or anti-anxiety medication, like Zoloft or Lexapro, in order to ensure that the patient has immediate relief from their most concerning symptoms while also creating a plan for long term management, allowing the patient to slowly wean off Ativan or Xanax.

Risks and Warnings

Due to their fast acting natures and sedative effects, both Xanax and Ativan have a high potential for psychological and physical dependence,  and their use can easily become habit forming. Therefore, there are several risks and warnings associated with both medications. First, patients who have struggled with addictive tendencies in the past should use extreme caution when taking these medications, because benzodiazepines like Xanax and Ativan have a higher risk of drug abuse among patients with a history of drug or alcohol use or alcohol withdrawal. Xanax and Ativan can cause a worsening of depression symptoms in patients who are suffering from depression, so it is important to tell someone if you notice your depression worsening or begin experiencing suicidal thoughts. Both Ativan and Xanax work on the central nervous system, so when used in combination with other central nervous system depressants, the drugs can cause fatal respiratory depression. Therefore, it is imperative that you tell your healthcare provider about any prescription drugs, over-the-counter medications, supplements, vitamins, or herbs you are taking in order to receive appropriate medical advice. Due to their addictive nature, Xanax and Ativan should only be prescribed for short periods of time, generally no more than four months. Continuous long term use is not recommended due to the potential for abuse, so any extension of use should be carefully considered by a medical professional. Due to the potential for serious birth defects and life-threatening withdrawal symptoms for the infant, neither Ativan or Xanax should be used by pregnant or breastfeeding mothers.

Dosing

Xanax

Both Xanax and its generic form, lorazepam, come in tablets of 0.25 mg, 0.5 mg, 1 mg, and 2 mg strengths. The extended-release tablets version of the medication is available in all of the aforementioned strengths as well as a 3 mg strength. Patients being treated with Xanax for anxiety generally start with a dose of 0.25 mg to 0.5 mg taken three times per day with a maximum daily dose of 4 mg. Those being treated for panic disorder are prescribed approximately 6 mg per day to start, while 10 mg per day is the limit. 

Ativan

Both Ativan and its generic form, lorazepam, come in tablets of 0.5 mg, 1 mg, and 2 mg strengths. When taken to manage symptoms of anxiety, the typical dosage of Ativan is 1 mg to 2 mg daily divided into two to three doses. When used to treat insomnia, approximately 2 mg to 4 mg is taken at bedtime. 

Side Effects

Side effects for Xanax and Ativan are generally divided into three categories and include common, less common, and serious side effects. Common side effects of Xanax include:

  • Ataxia
  • Cognitive dysfunction
  • Constipation
  • Difficulty in micturition
  • Drowsiness
  • Dysarthria
  • Fatigue
  • Memory impairment
  • Skin rash
  • Weight gain
  • Weight loss
  • Anxiety 
  • Blurred vision
  • Diarrhea
  • Insomnia 
  • Decreased libido
  • Increased appetite
  • Decreased appetite

Common side effects of Ativan are fewer in number than those of Xanax and include:

  • Drowsiness
  • Dizziness
  • Weakness

Less common side effects of Xanax include:

  • Hypotension
  • Sexual disorder
  • Muscle twitching
  • Increased libido

Less common side effects of Ativan include:

  • Confusion
  • Lack of coordination
  • Depression
  • Fatigue
  • Headaches
  • Restlessness

Serious side effects of both Xanax and Ativan include:

  • Slowed breathing
  • Respiratory failure
  • Psychological and physical dependence
  • Serious allergic reaction (antihistamines may be needed)
  • Suicidal thoughts

Be on the lookout for signs of psychological and/or physical dependence on Xanax or Ativan. Symptoms of dependence may include:

  • Anxiety
  • Depression 
  • Muscle weakness
  • Nightmares
  • Body aches
  • Sweating
  • Nausea
  • Vomiting 

If you experience an allergic reaction to Xanax or Ativan, you should seek medical attention immediately. Symptoms of an allergic reaction include:

  • Rash or hives
  • Trouble breathing or swallowing
  • Swelling of lips, tongue, or face
  • Rapid heartbeat

Withdrawal

Use of Xanax and Ativan can be habit forming, and due to the risk of physical and psychological dependence on these medications, withdrawal symptoms can occur if the medication is stopped abruptly. If you’ve been taking Xanax or Ativan regularly for more than two weeks, you must gradually start tapering off the medication under the supervision of a doctor to prevent withdrawal symptoms from occurring. The longer you have taken the medication, the more likely you are to experience withdrawal. Common withdrawal symptoms include:

  • Convulsions
  • Tremor
  • Cramps
  • Vomiting
  • Sweating
  • Insomnia

If you are severely dependent on either Xanax or Ativan, you could experience more serious symptoms, especially if the medication is stopped abruptly. These include:

  • Hallucinations
  • Seizures
  • Tremors
  • Panic attacks

Overdose

There is a risk of overdose for both Xanax and Ativan, especially when the medication is taken in conjunction with alcohol or opioid medications. Individuals who become dependent on either drug may find themselves taking more and more of the medication to produce the same calming effect. Eventually, this can lead to overdose, which is one of the reasons it is so important to take these medications only as prescribed and only for a short length of time. Signs of an overdose include: 

  • Extreme drowsiness
  • Confusion
  • Slurred speech
  • Feeling restless
  • Muscle weakness
  • Loss of balance or coordination
  • Lightheadedness
  • Slow heartbeats
  • Weak or shallow breathing 
  • Coma

Medical attention should immediately be sought in the event of an overdose or possible overdose of Xanax or Ativan.

Published May 12th, 2020 by Bridget Reed
Fact Checked by Chris Riley

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