ALPRAZOLAM

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Created Apr 2019 | Updated Oct 2020

ALPRAZOLAM

  • [XANAX]
  • [XANNY]
  • [NIRAVAM]

DEA CODE 2882: Schedule 4

Alprazolam is one of the most commonly prescribed and misused benzodiazepines in the United States

Alprazolam, a benzodiazepine, is used to treat panic disorder and anxiety disorder. Unlike chlordiazepoxide, clorazepate, and prazepam, alprazolam has a shorter half-life and metabolites with minimal activity. Clinically, all benzodiazepines cause a dose-related central nervous system depressant activity varying from mild impairment of task performance to hypnosis. Unlike other benzodiazepines, alprazolam may also have some antidepressant activity, although clinical evidence of this is lacking. Their exact mechanism of action is unknown. Benzodiazepines bind nonspecifically to benzodiazepine receptors BNZ1, which mediates sleep, and BNZ2, which affects muscle relaxation, anticonvulsant activity, motor coordination, and memory.

Alprazolam is used to treat anxiety disorders and panic disorder (sudden, unexpected attacks of extreme fear and worry about these attacks). Alprazolam is in a class of medications called benzodiazepines. It works by decreasing abnormal excitement in the brain.

  • Alprazolam comes as a tablet, an extended-release tablet, an orally disintegrating tablet, and a liquid to take by mouth.
  • Alprazolam may increase the risk of serious or life-threatening breathing problems, sedation, or coma if used along with certain medications.

Alprazolam drug usage

21st most prescribed medicine in the United States for 2017


The effects of mixing alprazolam and alcohol:
The relative ease of obtaining these two medications means that the combination is fairly prevalent. Both alcohol and alprazolam work to depress central nervous system functions. In combination, these two drugs work synergistically to dramatically increase the buzz effect normally experienced with alcohol. The euphoric high associated with heavy drinking is likewise increased when under the effects of alprazolam, and users may not be fully aware of the quantity of drugs they consume while under the mutual effect.

Alprazolam
Duration:

An extremely common benzodiazepine better known as Xanax, frequently prescribed for the treatment of anxiety and panic disorders. Alprazolam is short-lasting and primarily anxiolytic, though also possesses hypnotic properties. At high doses amnesia and loss of inhibition are common. Do not mix with other depressants.

NOTE: Warning - higher doses increase the chances of blacking out

RouteOnsetDurationAfter Effects
Tripsit Factsheets
All ROAs:15-40 minutes5-8 hours6-24 hours
Alprazolam Duration
Avoid:
When taken for a long period of time, abrupt discontinuation is highly unadvised. Avoid combining other depressants such as Alcohol.
Aliases:
  • Xanax
  • Prazolam
  • Ksalol
  • Niravam
Warning:
NOTE: Warning - higher doses increase the chances of blacking out
Effects:
Anxiolytic, Sedative, Muscle Relaxant, Amnesia, Dystaxia, Hiccups, Loss of time, Loss of motor skills.

Important Information:
You should not use alprazolam if you have narrow-angle glaucoma, if you also take itraconazole or ketoconazole, or if you are allergic to alprazolam or similar medicines (Valium, Ativan, Tranxene, and others).

Do not use alprazolam if you are pregnant. This medicine can cause birth defects or life-threatening withdrawal symptoms in a newborn.

Alprazolam may be habit-forming and should be used only by the person for whom it was prescribed. Keep the medication in a secure place where others cannot get to it. Misuse can cause addiction, overdose, or death.

Fatal side effects can occur if you take alprazolam with alcohol, opioid medicine, or other drugs that cause drowsiness or slow your breathing.

Avoid drinking alcohol. Dangerous side effects or death could occur.

Avoid driving or hazardous activity until you know how alprazolam will affect you. Dizziness or drowsiness can cause falls, accidents, or severe injuries.

Grapefruit may interact with alprazolam and lead to unwanted side effects. Avoid the use of grapefruit products.

Interactions:

Drug Interactions (473) Alcohol/Food Interactions (2) Disease Interactions (9)


What other drugs will affect Alprazolam?
Taking alprazolam with other drugs that make you sleepy or slow your breathing can cause dangerous side effects or death. Ask your doctor before using opioid medication, a sleeping pill, a muscle relaxer, prescription cough medicine, or medicine for depression or seizures. Tell your doctor about all your other medicines, especially:
  • Cimetidine
  • Digoxin
  • Birth control pills or hormone replacement therapy
  • An antidepressant - fluoxetine, fluvoxamine, nefazodone
  • An antibiotic - clarithromycin, telithromycin
  • Antifungal medicine - fluconazole, voriconazole
  • Antiviral medicine to treat HIV/AIDS - indinavir, nelfinavir, ritonavir, saquinavir
This list is not complete. Other drugs may interact with alprazolam, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible drug interactions are listed here.

A total of 473 drugs are known to interact with Alprazolam.

  • 33 major drug interactions
  • 400 moderate drug interactions
  • 40 minor drug interactions

Detection Windows:
Xanax is detectable in your blood, urine, saliva, and hair, but how long it's detectable depends on a variety of individual factors. Your age, weight, body fat, other medications, dose, length of time taking Xanax, hydration level, and metabolism all affect how long it takes for the drug to be eliminated from your system.

Here are the approximate detection window times for Xanax:

  • Urine: A urine drug screen, such as those that are done for employment, will test positive for benzodiazepines for five days and up to a week after a dose. For populations who metabolize Xanax more slowly - elderly, obese, Asian, and those with an alcoholic liver disease - that time maybe even longer.
  • Saliva: Xanax can be detected in saliva for up to 2.5 days.
  • Hair: As with all drugs, Xanax can be detected in your hair starting two to three weeks after and for up to 90 days after your last dose.
  • Blood: Blood levels may be done as a screening test or in cases of treatment for a suspected overdose, but they can only tell if you've taken Xanax in the last 24 hours.

Breastfeeding:

Summary of Use During Lactation:
Because of reports of effects in infants, including sedation, alprazolam is probably not the best benzodiazepine for repeated use during nursing, especially with a neonate or premature infant.

A shorter-acting benzodiazepine without active metabolites is preferred.

After a single dose of alprazolam, there is usually no need to wait to resume breastfeeding.

Effects on Lactation and Breastmilk:
Unlike other benzodiazepines, alprazolam can increase serum prolactin.

Alternate Drugs to Consider:

Xanax (alprazolam)
Maximum Dosage:
Prescribers Digital Reference
Adults:10 mg/day PO.
Geriatric:10 mg/day PO.
Adolescents:Safety and efficacy have not been established; 0.06 mg/kg/day PO (immediate-release tablets or oral solution) has been suggested for the treatment of anxiety.
Children:7 years and older: Safety and efficacy have not been established; 0.06 mg/kg/day PO (immediate-release tablets or oral solution) has been suggested for the treatment of anxiety.
Children:Less than 7 years: Safety and efficacy have not been established.

Pediatric:
Appropriate studies have not been performed on the relationship of age to the effects of alprazolam in the pediatric population.

Safety and efficacy have not been established.

Geriatric:
Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of alprazolam in the elderly. However, elderly patients are more likely to have unwanted effects (eg, severe drowsiness, dizziness, confusion, clumsiness, or unsteadiness) and kidney, liver, or lung problems, which may require caution and an adjustment in the dose for patients receiving this medicine.

Other Interactions:

  • Grapefruit Juice

Other Medical Problems:
Make sure you tell your doctor if you have any other medical problems, especially:

  • Alcohol abuse, history of
  • Depression, or history of
  • Drug abuse or dependence, history of
  • Lung or breathing problems (eg, respiratory depression)
  • Mania, or history of
  • Mental health problems, or history of
  • Seizures, or history of - Use with caution. May make these conditions worse
  • Glaucoma, acute narrow angle - Should not be used in patients with this condition
  • Kidney disease
  • Liver disease - Use with caution. The effects may be increased because of slower removal of the medicine from the body

Xanax, Niravam (alprazolam) (Rx)
Black Box Warnings:
Concomitant use of benzodiazepines and opioids may result in profound respiratory depression, coma, and death; administer concomitantly when there are no alternative options; limit dosages and durations to minimum required; monitor for signs and symptoms of respiratory depression and sedation

Addiction, abuse, and misuse

  • On September 2020, FDA addressed serious risks of benzodiazepine addiction, abuse, and misuse, which can lead to overdose and death
  • Physical dependence can occur when taken steadily for several days to weeks, even as prescribed
  • Stopping abruptly or reducing dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening
  • Assess each patient's risk prior to prescribing and monitor regularly for the development of these behaviors or conditions

Liver:
As with most benzodiazepines, alprazolam therapy has not been associated with serum aminotransferase or alkaline phosphatase elevations, and clinically apparent liver injury from alprazolam has been reported, but is very rare.

Alprazolam Hepatotoxicity:
Alprazolam, like other benzodiazepines, is rarely associated with serum ALT elevations, and clinically apparent liver injury from alprazolam is extremely rare. There have been a few case reports of acute liver injury from alprazolam and recurrence on reexposure has been reported. In alprazolam related cases of acute liver injury, the latency has been within a few weeks and the typical pattern of liver enzyme elevations has been cholestatic or mixed (Case 1). The injury is usually mild-to-moderate in severity and self-limited. Fever and rash have not been described nor has autoantibody formation.

D Likelihood score: D (possible rare cause of clinically apparent liver injury).


Xanax (alprazolam)
Side Effects:
Get emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.
RxList
Call your doctor at once if you have:
  • depressed mood, thoughts of suicide or hurting yourself
  • racing thoughts, increased energy, unusual risk-taking behavior
  • confusion, agitation, hostility, hallucinations
  • uncontrolled muscle movements, tremor, seizure (convulsions)
  • pounding heartbeats or fluttering in your chest
Common side effects may include:
  • drowsiness, feeling tired
  • slurred speech, lack of balance or coordination
  • memory problems
  • feeling anxious early in the morning
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

HRES PDF Alprazolam

BFARM PDF Alprazolam

In 2017, it was the 21st most commonly prescribed medication in the United States, with more than 25 million prescriptions

  • A short-acting tranquilizer (benzodiazepine)
  • Used in short-term management of anxiety disorders, specifically panic disorder or generalized anxiety disorder (GAD improvement occurs generally within a week)
  • Due to concerns about misuse, some do not recommend alprazolam as an initial treatment for panic disorder
  • Alprazolam is generally taken by mouth
  • The maximum recommended daily dose is 10 milligrams per day
  • Patented in 1971
  • Approved for medical use in the United States in 1981

Common side effects include sleepiness, depression, headaches, feeling tired, dry mouth, and memory problems. Some of the sedation and tiredness may improve within a few days.

Alcohol is one of the most common interactions; alcohol and alprazolam taken in combination have a synergistic effect on one another, which can cause severe sedation, behavioral changes, and intoxication. The more alcohol and alprazolam taken, the worse the interaction.

  
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