Alprazolam (Xanax®) versus Lorazepam (Ativan®)

by eMedExpert staff
Medical references reviewed: August, 2018

Which is stronger Ativan® or Xanax®?

Many people wonder is lorazepam stronger than alprazolam. Alprazolam (Xanax) is more potent benzodiazepine than Lorazepam (Ativan).

How many mg of Ativan® equals Xanax®?

It should be noted that potency equivalence between benzodiazepine drugs is not clearly established.

The approximate equivalent dose of lorazepam to 10 mg diazepam: 1.7 mg 1.

The approximate equivalent dose of alprazolam to 10 mg diazepam: 1 mg 1.

So alprazolam 1 mg is equipotent to lorazepam 1.7 mg.


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Can you mix Ativan® and Xanax®?

There are no strict contraindications regarding the use of two benzodiazepines. Concomitant use of two different benzodiazepines is exceedingly rare in practice and is not recommended. If you have questions regarding the medications prescribed to you, please check with your doctor.

Difference between Alprazolam and Lorazepam chart

From the comparison chart below you can see what is common and what is different between the two benzos:

Alprazolam Lorazepam
• Xanax ®
• Xanax XR®
• Ativan®
Drug class
Benzodiazepines,
Anti-anxiety drugs
Dose formulations
• Tablets
• Tablets, extended-release
• Tablets, orally disintegrating
• Oral solution
• Tablets
• Oral concentrate
• Injectable solution
Legal status
• Controlled substance, Schedule IV
• Prescription only
FDA-approved indications
• Anxiety disorder
• Panic attacks
• Excessive anxiety
• Status epilepticus
• Pre-anesthetic for preoperative sedation and anxiety relief
"Off-label" uses
• Premenstrual syndrome • Panic disorder
• Acute mania
• Social anxiety disorder
• Depression (fast improvement of symptoms) 2
• Dental work and other surgical procedures to relax the patient
• Decrease of alcohol and sedative-hypnotic withdrawal symptoms
• Insomnia
Mechanism of action
• All benzodiazepines have a common molecular structure and similar mechanism of action.
• Benzodiazepines work by stimulating the action of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS.
Half-life
• 11.2 hours • 12-15 hours
Oral bioavailability
• 90%, well-absorbed orally • 90%, well-absorbed orally
Metabolism, Elimination
• Alprazolam is metabolized by the liver, primarily by cytochrome CYP3A4.
It is metabolized to two major metabolites: 4-hydroxyalprazolam and α-hydroxyalprazolam.
• Alprazolam and its metabolites are excreted primarily by kidneys and some via feces.
• Metabolism of lorazepam is different from other benzodiazepines as it is metabolized in the liver by the process of glucuronidation.
• Lorazepam is not metabolized by cytochrome P450 enzymes.
• Lorazepam is extensively conjugated to the 3- O-phenolic glucuronide in the liver and undergoes enterohepatic recirculation.
• 88% of lorazepam is excreted in the urine (with 75% excreted as the glucuronide) and 7% in feces.
Contraindications
• Concomitant use with CYP3A4 inhibitors (e.g. itraconazole, ketoconazole) • Myasthenia gravis
• Hypersensitivity to benzodiazepines
• Acute narrow angle glaucoma
Warnings & precautions
• Risk of dependence
• Tolerance - long term use leads to tolerance and reduced therapeutic effect
• Withdrawal symptoms upon discontinuation of a drug
• Depression of CNS function
• Daytime sedation
• Amnesiac effects - high benzodiazepine doses may cause amnesia
Side effects
• Drowsiness
• Sedation
• Somnolence
• Fatigue
• Weakness
• Lightheadedness
• Memory impairment, confusion
• Impaired motor coordination
Pregnancy category
• D

From the analysis of clinical trials you can conclude which medication is better for a specific medical condition.


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Alprazolam vs Lorazepam for Panic Attacks

Important distinction here is that Xanax® has FDA approval for treatment of panic disorder, while Ativan® has not.

Lorazepam is as effective as alprazolam in the acute treatment of panic disorder5, 6.

Alprazolam vs Lorazepam for Sleep and Insomnia

Both alprazolam and lorazepam are used to treat sleep problems "off-label". Benzodiazepines reduce sleep onset latency (time to get to sleep), decreased duration of slow-wave sleep, and improve sleep quality.

Lorazepam dosage for insomnia from anxiety: 2-4 mg at bedtime.

Alprazolam dosage for insomnia: 0.25-1 mg at bedtime7.

The utility of alprazolam and lorazepam in the treatment of sleep problems is limited by a relatively rapid development of tolerance to hypnotic effects and occurrence of rebound insomnia8.

Alprazolam advantages over Lorazepam

Is Alprazolam better than Lorazepam?

  • Alprazolam appears to be a more appropriate benzodiazepine for treating immunocompromised patients3.
  • Lorazepam provides more significant prolongation of reaction time, while alprazolam produces less impairment4.
  • Alprazolam is absorbed more rapidly and produces a quick anxiolytic effect.

Lorazepam advantages over Alprazolam

Is Lorazepam better than Alprazolam?

  • Lorazepam is a bit less addictive than alprazolam.
  • Lorazepam is considered to be best tolerated benzodiazepine by patients with liver disease.
  • Lorazepam is metabolized solely through conjugation and has fewer CYP450 drug interactions.

Further reading

References

  • 1. Kroll DS, Nieva HR, Barsky AJ, Linder JA. Benzodiazepines are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care. J Gen Intern Med. 2016 Sep;31(9):1027-34 PubMed
  • 2. Laakman G, Faltermaier-Temizel M, Bossert-Zaudig S, Baghai T, Lorkowski G. Treatment of depressive outpatients with lorazepam, alprazolam, amytriptyline and placebo. Psychopharmacology (Berl). 1995 Jul;120(1):109-15.
  • 3. Covelli V, Maffione AB, Greco B, Cannuscio B, Calvello R, Jirillo E.In vivo effects of alprazolam and lorazepam on the immune response in patients with migraine without aura. Immunopharmacol Immunotoxicol. 1993 Aug;15(4):415-28.)
  • 4. Crombez G, Kupers R, Adriaensen H.The effects of a single oral dose of lorazepam and alprazolam on reaction times in young healthy volunteers. Acta Anaesthesiol Belg. 1991;42(2):79-84.
  • 5. Schweizer E, Pohl R, Balon R, Fox I, Rickels K, Yeragani VK. Lorazepam vs. alprazolam in the treatment of panic disorder. Pharmacopsychiatry. 1990 Mar;23(2):90-3.
  • 6. Charney DS, Woods SW. Benzodiazepine treatment of panic disorder: a comparison of alprazolam and lorazepam. J Clin Psychiatry. 1989 Nov;50(11):418-23.
  • 7. Bonnet MH, Kramer M, Roth T. A dose response study of the hypnotic effectiveness of alprazolam and diazepam in normal subjects. Psychopharmacology (Berl). 1981;75(3):258-61.
  • 8. Kales A, Bixler EO, Vela-Bueno A, Soldatos CR, Manfredi RL. Alprazolam: effects on sleep and withdrawal phenomena. J Clin Pharmacol. 1987 Jul;27(7):508-15. PubMed

Published: April 05, 2018
Last updated: July 07, 2018

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