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busPIRone (Monograph)

Brand names: BuSpar, BuSpar Dividose
Drug class: Anxiolytics, Sedatives, and Hypnotics; Miscellaneous
VA class: CN309
Chemical name: 8-[4-[4-(2-Pyrimidinyl)-1-piperazinyl] butyl]-8-azaspiro[4.5]decane-7,9-dione monohydrochloride
Molecular formula: C21H31N5O2•HCl
CAS number: 33386-08-2

Medically reviewed by Drugs.com on May 22, 2023. Written by ASHP.

Introduction

Anxiolytic agent;2 4 70 89 112 131 132 133 structurally and pharmacologically different than benzodiazepines, barbiturates, and other available anxiolytic agents.1 2 4 6 70 78 112 132 133 187

Uses for busPIRone

Anxiety Disorders

Management of anxiety disorders (anxiety and phobic neuroses)1 2 5 36 37 38 39 40 41 42 45 72 81 83 88 95 107 109 123 189 191 and short-term relief of symptoms of anxiety.1 2 47 72 123

Efficacy generally comparable to that of benzodiazepines (e.g., alprazolam,45 83 clorazepate,40 42 83 184 diazepam, 36 37 38 39 40 41 72 81 83 88 107 109 130 160 lorazepam) in the management of generalized anxiety disorder (GAD).45 83

Preferred by some clinicians for the management of anxiety disorders in patients with a history of aggression or in whom disinhibition has occurred during benzodiazepine therapy.154 185 186

busPIRone Dosage and Administration

General

Administration

Oral Administration

Administer orally in a consistent manner, either always with or always without food.1 (See Food under Pharmacokinetics.)

The 15- and 30-mg tablets (Dividose tablets) are scored to be broken in 2 halves (each providing a dose of 7.5 and 15 mg, respectively) or in 3 thirds (each providing a dose of 5 and 10 mg, respectively).1

Dosage

Available as buspirone hydrochloride; dosage is expressed in terms of the salt.1

Adults

Anxiety Disorders
Oral

Initially, 10–15 mg daily in 2 or 3 divided doses.1 2 37 38 41 45 47 49 72 83 123 191 193 Increase dosage in increments of 5 mg daily every 2–4 days according to individual response and tolerance.1 2 5 37 38 41 72 83 123 Maintenance, 15–30 mg daily in 2 or 3 divided doses.1 37 38 39 40 41 42 45 47 48 51 59 114 123 191

Reduced dosage recommended in patients receiving concomitant therapy with potent CYP3A4 inhibitor.1 (See Drugs Affecting Hepatic Microsomal Enzymes under Interactions.)

Prescribing Limits

Adults

Maximum 60 mg daily.1 2 123

Special Populations

Hepatic Impairment

Prolonged elimination.1 Consider dosage reduction.1 34 110 112 Manufacturer states that use in patients with severe hepatic impairment is not recommended.1

Renal Impairment

Some clinicians recommend that dosage be reduced by 25–50% in anuric patients.104 However, other clinicians state that dosage recommendations cannot be made for patients with renal impairment due to variability in plasma buspirone concentrations.204 205 (See Absorption under Pharmacokinetics.) Manufacturer states that use in patients with severe renal impairment is not recommended.1

Detailed Buspirone dosage information

Cautions for busPIRone

Contraindications

Warnings/Precautions

Warnings

MAO Inhibitors

Avoid concomitant use.1 2 63 (See Specific Drugs under Interactions.)

Psychiatric Indications

No established antipsychotic efficacy at usual dosages;1 2 51 61 62 70 80 83 84 85 86 87 88 89 90 100 112 122 should not be used in place of appropriate antipsychotic therapy.1 2

General Precautions

CNS Effects

Generally does not produce substantial impairment of cognitive or psychomotor function at usual dosages; however, CNS effects show interindividual variation and may not be predictable.1 2

Prudent to avoid concomitant use with alcohol.1 2 (See Specific Drugs under Interactions.)

Benzodiazepine or Sedative/Hypnotic Withdrawal

No cross-tolerance with benzodiazepines or other sedative/hypnotic drugs; will not prevent symptoms of withdrawal following cessation of such therapy.1 2 6 39 44 60 70 71 86 124 Withdraw therapy with such drugs gradually in patients being switched to buspirone, particularly following prolonged or relatively high-dose therapy.1 2 39 86

Dopaminergic Effects

Potential for causing changes in dopamine-mediated neurologic function (e.g., dystonia, parkinsonian-like manifestations, akathisia, tardive dyskinesia) not fully elucidated.1 186

Specific Populations

Pregnancy

Category B.1

Lactation

Buspirone and its metabolites are distributed into milk in rats.1 Avoid whenever clinically possible.1

Pediatric Use

Safety and efficacy not established in children <18 years of age.1 Has been used in pediatric patients 6–17 years of age with GAD without unusual adverse effects; however, dosage of 7.5–30 mg twice daily for 6 weeks was no more effective than placebo.1

Geriatric Use

No substantial differences in safety, efficacy, or phamacokinetic profile relative to younger adults; however, increased sensitivity cannot be ruled out.1

Hepatic Impairment

Prolonged elimination.1 Use with caution.1 34 110 112

Manufacturer states that use in patients with severe hepatic impairment is not recommended.1

Renal Impairment

Decreased clearance.1 Use with caution.1 34 104 112 Need for dosage adjustment not fully elucidated. (See Renal Impairment under Dosage and Administration.)34 104 112

Manufacturer states that use in patients with severe renal impairment is not recommended.1

Common Adverse Effects

Dizziness, nausea, headache, nervousness, drowsiness, light-headedness, excitement.1 2 5 36 37 38 42 45 58 61 62 89 114 123 130 191

Drug Interactions

Metabolized by CYP3A4.1 4 5 15 31 32 34 64 112 125

Drugs Affecting Hepatic Microsomal Enzymes

Possible pharmacokinetic interaction (increased plasma buspirone concentrations) with CYP3A4 inhibitors.1 Low buspirone dosage (i.e., 2.5 mg once or twice daily) recommended in patients receiving potent CYP3A4 inhibitor; base subsequent adjustments of buspirone and CYP3A4 inhibitor dosage on clinical assessment.1

Possible pharmacokinetic interaction (decreased plasma buspirone concentrations) with CYP3A4 inducers.1 May require dosage adjustment to maintain anxiolytic effect.1

Protein-bound Drugs

Possible displacement from binding sites of buspirone or other protein-bound drugs.1 2 34 94

One report of increased prothrombin time when buspirone was added to a regimen of warfarin, phenytoin, phenobarbital, digoxin, and levothyroxine (Synthroid); clinical importance unknown.1

Specific Drugs and Foods

Drug or Food

Interaction

Comments

Alcohol

Does not appear to alter blood alcohol concentrations50 51 73 or substantially potentiate alcohol-induced impairment of psychomotor and cognitive performance2 5 10 34 48 50 51 55 73 74 76 90 93 105 112

Prudent to avoid concomitant use1

Amitriptyline

No interaction reported1 2 34 59

Cimetidine

Possible decrease in buspirone clearance 1 119 120 204

Clinical importance not established1

CNS depressants (e.g., analgesics, antihistamines, sedative/hypnotics including benzodiazepines)

Possible CNS depression, although few interactions reported to date2 5 34 48 63 76 81 91 93 112 123 129

Use with caution1 105

Diltiazem

Increased plasma buspirone concentrations1

Buspirone dosage adjustment may be necessary1

Erythromycin

Increased plasma buspirone concentrations1 204 and increased incidence of adverse effects attributable to buspirone1

Decrease buspirone dosage (e.g., 2.5 mg twice daily); base subsequent adjustments of buspirone and erythromycin dosage on clinical assessment1

Grapefruit juice

Increased plasma buspirone concentrations1

Avoid drinking large amounts of grapefruit juice1

Haloperidol

Increased serum haloperidol concentrations2 97

Clinical importance not established1

Itraconazole

Increased plasma buspirone concentrations1 204 and increased incidence of adverse effects attributable to buspirone1

Decrease buspirone dosage (e.g., 2.5 mg daily); base subsequent adjustments of buspirone and itraconazole dosage on clinical assessment1

MAO inhibitors (e.g., tranylcypromine)

Increased blood pressure;1 2 63 196 197 possible contribution to a fatal case of serotonin syndrome when used concomitantly with fluoxetine and tranylcypromine201 202

Do not use concomitantly;1 2 63 196 197 allow 10 days between discontinuance of MAO inhibitor and administration of buspirone196 197

Nefazodone

Marked increase in plasma buspirone concentration; slight increase in concentrations of nefazodone and its metabolite1

Use with caution; decrease buspirone dosage (e.g., 2.5 mg daily); base subsequent adjustments of buspirone and nefazodone dosage on clinical assessment1

Rifampin

Decreased plasma buspirone concentrations1

Adjust buspirone dosage as necessary to maintain anxiolytic effect1

Trazodone

Possible elevation of serum ALT1 2

Verapamil

Increased plasma buspirone concentrations1

Buspirone dosage adjustment may be necessary1
Buspirone drug interactions (more detail)

busPIRone Pharmacokinetics

Absorption

Bioavailability

Rapidly1 2 4 5 29 34 64 88 and almost completely absorbed following oral administration.2 34 64 112 116 Undergoes extensive first-pass metabolism in the liver;1 2 4 31 34 64 112 116 only about 4% of a dose reaches systemic circulation unchanged.2 31 34 104 112 116

Peak plasma concentrations occur within 40–90 minutes following oral administration.1 2 4 29 31 34 64 65 115

Onset

Anxiolytic activity may be apparent within the first 2 weeks,38 123 but optimum therapeutic effect usually requires at least 3–4 weeks39 41 123 193 and occasionally up to 4–6 weeks.87

Food

Food may delay absorption, thereby decreasing the extent of presystemic clearance1 2 34 and increasing the amount of unchanged buspirone reaching systemic circulation.1 2 5 30 34

Distribution

Extent

Extensively distributed into body tissues in animals.112 127

Buspirone and metabolites are distributed into milk in animals;1 123 extent of distribution into human milk is unknown.1 123 185

Plasma Protein Binding

Approximately 86–95%1 2 34 104 203 (mainly albumin; α1-acid glycoprotein to a lesser extent).34 35

Elimination

Metabolism

Extensively metabolized in the liver, mainly via oxidation by CYP3A4.1 4 5 15 31 32 34 64 112 125

In animals, the major active metabolite (1-pyrimidinylpiperazine)1 5 15 31 32 33 34 112 125 has about 20–25% of the anxiolytic activity of buspirone but is present in the brain in concentrations up to 15-to 30-fold greater than those of unchanged drug.1 2 34 112 125 129 Contribution to the drug’s effects in humans is not fully elucidated.2 5 15

Elimination Route

Excreted principally in urine and to a lesser extent in feces;1 2 34 112 excreted mainly as metabolites.2 5 31 34 64 104 112

Half-life

2–4 hours.1 2 4 15 29 31 34 65 104 110 112 115 116

Special Populations

Elimination half-life may be prolonged in patients with renal impairment, particularly in those with anuria,34 104 and in patients with liver impairment, including those with cirrhosis.1 34 110 112

Stability

Storage

Oral

Tablets

Tight, light-resistant containers at ≤30°C.1 185

Actions

Advice to Patients

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

busPIRone Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets

5 mg*

BuSpar (scored)

Bristol-Myers Squibb

Buspirone Hydrochloride (scored)

Aegis

7.5 mg*

Buspirone Hydrochloride (with povidone; scored)

Par

10 mg*

BuSpar (multi-scored)

Bristol-Myers Squibb

Buspirone Hydrochloride (scored)

Aegis

15 mg*

BuSpar Dividose (scored)

Bristol-Myers Squibb

Buspirone Hydrochloride (multi-scored)

Aegis

30 mg*

BuSpar Dividose (multi-scored)

Bristol-Myers Squibb

Buspirone Hydrochloride (multi-scored)

Mylan

AHFS DI Essentials™. © Copyright 2024, Selected Revisions June 1, 2006. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

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