Ativan and Xanax are benzodiazepines. Doctors use benzodiazepines to treat a variety of conditions, including panic disorders, anxiety disorders, insomnia, and mania.

Although Ativan (lorazepam) and Xanax (alprazolam) have many similarities, doctors recognize their differences and select which one to use based on their unique properties.

This article looks at the similarities and differences between Ativan and Xanax, including their uses, how they work, and their adverse effects, including withdrawal and misuse potential.

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Ativan and Xanax are second-line treatment drugs for anxiety disorders.

Ativan and Xanax share many similarities. They work in the same manner, have the possibility of dependence and misuse, and cause similar adverse effects.

Ativan and Xanax work by binding to receptors in the brain, resulting in a calming effect.

These two drugs also have disadvantages, including impaired motor skills, drowsiness, and withdrawal symptoms upon stopping.

The Anxiety and Depression Association of America (ADAA) recommend Ativan or Xanax as a second-line treatment for general anxiety disorders. This means that doctors may use one of these drugs when first-line treatments are not appropriate or not effective.

First-line medications, according to the ADAA and the American Psychiatric Association, are selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). These include venlafaxine XR, duloxetine, escitalopram, and paroxetine.

Healthcare professionals often prefer to prescribe SSRIs and SNRIs because they have little potential for misuse, while people can become dependent on benzodiazepines.

Since Ativan and Xanax have a high potential for misuse, people with a history of drug or alcohol dependency should exercise caution when using these drugs.

In the United States, benzodiazepine use is more common among women and increases with age. However, older adults are more sensitive to the effects of benzodiazepines, which means they have more side effects, including a higher risk of falls and fractures.

Ativan treats more conditions than Xanax. The Food and Drug Administration (FDA) have approved the following uses:

  • Xanax: Treatment of anxiety and panic disorders.
  • Ativan tablets: Treatment of anxiety disorders.
  • Ativan injection: Treatment of seizures and premedication for anesthesia.

Doctors may prescribe the drugs for other purposes, but these are off-label uses. They do not have FDA approval.

Ativan acts slower, and the body removes it slower than it does Xanax. This means that the effects of Ativan take longer to kick in but last for longer compared with those of Xanax. Because of this, people may take Ativan less frequently than Xanax.

An oral dose of Xanax reaches its highest concentration in 1–2 hours, while it takes an oral dose of Ativan around 2 hours.

The average half-life for Xanax, or the time taken for the body to remove half of the drug, is 11.2 hours. The body removes Ativan more slowly, with a half-life of 12 hours, or 18 hours for Ativan and its byproducts.

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Side effects of benzodiazepines can include drowsiness and fatigue.

The most common side effects of benzodiazepines include:

  • drowsiness
  • memory problems
  • confusion
  • fatigue
  • slurred speech
  • decreased libido
  • constipation
  • increase appetite
  • weakness
  • impaired balance and coordination
  • impaired driving skills
  • euphoria

This is a partial list of side effects. People should talk with their doctor about all of the possible adverse effects.

While both drugs can cause drowsiness, this is less likely with Ativan than Xanax.

Ativan may cause drowsiness in 15.9% of people taking the drug for anxiety. Xanax may cause drowsiness in 41% of people taking it for anxiety and 76.8% of people taking it for panic disorder.

Ativan can impair learning and coordination and cause amnesia for longer periods than Xanax.

The properties of each drug play a role in how common and severe the withdrawal symptoms are and the drugs’ potential for misuse.

In general, Ativan causes fewer withdrawal symptoms and has less potential for misuse than Xanax. This is likely because Ativan has a more prolonged effect and slower elimination rate than Xanax.

It is more likely that missed doses or abruptly stopping Xanax can cause rapid withdrawal effects, including anxiety, insomnia, and panic attacks.

Benzodiazepine withdrawal symptoms include:

  • anxiety
  • panic
  • nausea or vomiting
  • diarrhea
  • hallucinations
  • insomnia
  • drug cravings
  • muscle twitches
  • tingling in the arms and legs
  • cognitive deficits
  • mood swings

The severity of the withdrawal symptoms depends on the length of treatment, type of drug, dosage, underlying medical conditions, and use of other drugs or alcohol.

People taking benzodiazepines may develop dependence at low dosages as well as high dosages, and this can develop within several weeks.

If a person takes Xanax or Ativan for a month or longer, they should slowly reduce the drug to minimize withdrawal symptoms. Even when decreased over several weeks, people may still experience withdrawal symptoms for 1 week to several weeks, which may make it difficult to stop the medication.

A person should never change their dose or stop taking the medication without speaking with their doctor. Their doctor will put together a plan with them.

Rare, severe withdrawal symptoms include seizures, psychosis, and confusion.

Ativan and Xanax interact with opioids, tricyclic antidepressants, barbiturates, and alcohol. Taking them together increases the risk of severe drowsiness, overdose, and death.

Ativan and Xanax interact with several other drugs. It is best to have a doctor or pharmacist review any current medication before starting to take a benzodiazepine.

This is a partial list of interactions. People should talk with their doctor or pharmacist to review all their medications and possible interactions before using these drugs.

Black box warning: Risks of using benzodiazepines with opioids

  • Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.
  • Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.
  • Limit dosages and durations to the minimum required.
  • Follow patients for signs and symptoms of respiratory depression and sedation.

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A doctor will prescribe the dosage of Ativan or Xanax depending on the condition that they are treating.

The dosages of Ativan and Xanax depend on their forms and the condition they are helping to treat.

In many cases, people may take larger doses of Ativan, at 2–6 milligrams (mg) per day, compared with Xanax, which people usually take at less than 4 mg per day. People taking Xanax for panic disorder may take higher doses.

Ativan is also available as an injection, but Xanax is not. Xanax is available in a disintegrating tablet and a 24-hour long-acting tablet, while Ativan is not.

Forms

Xanax comes in the following forms and dosages:

  • liquid: 1 milligram per milliliter (mg/ml)
  • immediate release tablet: 0.25 mg, 0.5 mg,1 mg, 2 mg
  • disintegrating tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg
  • extended release 24-hour tablet: 0.5 mg, 1 mg, 2 mg, 3 mg

Ativan comes in the following forms and dosages:

  • liquid: 2 mg/ml
  • injections: 2 mg/ml, 4 mg/ml
  • tablets: 0.5 mg, 1 mg, 2 mg

Dosages

The dosages for Xanax immediate-release tablets are as follows:

  • Anxiety: start with 0.25–0.5 mg three times daily, which can be titrated up to a max of 4 mg three times daily for maximum benefit.
  • Panic disorders: A starting dose of 0.5 mg three times daily, which can increase over several weeks to a maximum of 10 mg daily.

The dosages for Xanax tablets, orally disintegrating, and liquid solution are as follows:

  • Panic disorders: Your doctor will work with you to find the best dose. In clinical trials, doses of 1 to 10mg daily were used.

The dosages for extended-release Xanax tablets are as follows:

  • Anxiety and panic disorders: 3 mg to 6 mg taken once daily, generally in the morning.

The dosages for Ativan tablets and liquid are as follows:

  • Anxiety: The usual dose is 2 mg to 6 mg daily, divided into equal doses.

The dosages for Ativan injection are as follows:

  • Seizures (epilepsy): A 4 mg injection given once slowly by a healthcare provider. An additional 4 mg injection can be given 10-15 minutes later if needed.

The dosage for Ativan injection is as follows:

  • Preanesthesia: 0.05 mg/kg, up to 4 mg total, given by a healthcare provider.

According to GoodRx:

The final cost will depend on the individual’s insurance coverage.

People should talk with their doctor if they are, are planning to, or might become pregnant.

Benzodiazepines have not been proven safe for a fetus.

Respiratory (breathing) problems have been noted in babies born to mothers who were taking benzodiazepines. Other possible adverse effects include low birth weight, low blood sugars, and withdrawal symptoms.

People should use other therapies when treating panic disorders during pregnancy. If a benzodiazepine is necessary, doctors usually prefer to prescribe other types than Xanax.

Drug manufacturers do not recommend taking a benzodiazepine while breastfeeding.

Ativan and Xanax are both benzodiazepines. They have similar effects and side effects, and both can cause withdrawal symptoms. However, one may work better for some people than the other.

Despite the similarities between Ativan and Xanax, their properties result in a number of differences. A doctor will prescribe one or the other based on a person’s medical history and current condition.

Recommendations suggest using antidepressants over Ativan or Xanax in the treatment of anxiety disorders or panic disorders because benzodiazepines have the potential for withdrawal and misuse.

Although official guidance does not recommend Ativan or Xanax as first-line treatments and they have significant adverse effects, they both are a significant portion of prescribed benzodiazepines.