Ativan vs. Xanax: What are the differences?
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.
What are they?
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. They also have a high potential for misuse.
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 or Xanax have a high potential for misuse, people with a history of drug or alcohol dependency should exercise caution when using these drugs.
Which conditions do they treat?
Ativan treats more conditions than Xanax. The Food and Drug Administration (FDA) have approved Ativan for:
- the treatment of anxiety disorders
- the treatment of insomnia
- premedication for anesthesia
- the treatment of seizures
They have approved Xanax for anxiety disorders and panic disorder.
How quickly do they work?
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, and they last for longer compared with those of Xanax. Because of this, people may take Ativan less frequently than Xanax.
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.
What are the adverse effects?
Side effects of benzodiazepines can include drowsiness and fatigue.
Both drugs can cause drowsiness, but this is less likely with Ativan than Xanax.
Ativan can impair learning and coordination and cause amnesia for longer periods than Xanax.
The most common side effects of benzodiazepines include:
- memory problems
- slurred speech
- decreased libido
- increase appetite
- impaired balance and coordination
- impaired driving skills
What is the likelihood of withdrawal and misuse?
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.
Xanax may also be involved in more overdoses than Ativan.
Benzodiazepine withdrawal symptoms include:
- nausea or vomiting
- 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.
Ativan and Xanax can lead to more withdrawal symptoms than other benzodiazepines. Of the two, Xanax can cause more significant withdrawal symptoms.
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.
Rare, severe withdrawal symptom include seizures, psychosis, and confusion.
What are the drug interactions?
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 drugs. It is best to have a doctor or pharmacist review any current medication before starting to take a benzodiazepine.
How to take Ativan and Xanax
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.
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
The dosages for Xanax immediate-release tablets are as follows:
- Anxiety: A starting dose of 0.25–0.5 mg three times daily, which can increase every 3– 4 days at no more than 1 mg per day to a maximum of 4 mg daily, in divided doses.
- 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 extended-release Xanax tablets are as follows:
- Panic disorders: A starting dose of 0.5–1 mg once daily in the morning, which can increase in 3–4 day intervals at no more than 1 mg per day over several weeks to an average maximum of 6 mg per day. However, some people may require up to 10 mg daily.
The dosages for Ativan oral tablets are as follows:
- Anxiety: A starting dose of 2–3 mg two to three times daily, which can increase over several weeks to a maximum of 10 mg daily.
- Insomnia: A single dose of 2–4 mg at bedtime.
How much do they cost?
According to GoodRx:
- Ativan 1 mg costs $5.66 for 30 tablets.
- Xanax 0.5 mg costs about $4.05 for 30 tablets.
- Xanax 1 mg extended-release costs about $16.81 for 30 tablets.
Pregnancy and breastfeeding
Benzodiazepines can cause harm to the fetus, including low birth weight, low blood sugars, breathing problems, 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.
Despite the similarities between Ativan and Xanax, their properties result in a number of differences. These properties make Xanax more useful for panic disorder and Ativan more useful for insomnia, premedication for anesthesia, and seizures.
Xanax can cause more potent side effects, such as drowsiness and euphoria, but the length of these effects are shorter than that which Ativan causes. Xanax may cause worse withdrawal symptoms.
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 hold a significant portion of prescribed benzodiazepines, and this is unlikely to change in the near future.