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قرص xanax xr
قرص xanax xr

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قرص xanax xr

 

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Kaiser Permanente health plans around the country: Kaiser Foundation Health Plan, Inc., in Northern and Southern California and Hawaii • Kaiser Foundation Health Plan of Colorado • Kaiser Foundation Health Plan of Georgia, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 404-364-7000 • Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., in Maryland, Virginia, and Washington, D.C., 2101 E. Jefferson St., Rockville, MD 20852 • Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 100, Portland, OR 97232 • Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc., 601 Union St., Suite 3100, Seattle, WA 98101

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8-Chlor-1-methyl-6-phenyl-4H-[1,2,4]-triazolo[4,3-a][1,4]benzodiazepin

N05BA12

Feststoff[1]

228–228,5 °C[1]

2,4[3]

قرص xanax xr

löslich in Ethanol, unlöslich in Wasser[1]

Achtung

1220 mg·kg−1 (LD50, Ratte, oral)[4]


Alprazolam ist ein Arzneistoff aus der Gruppe der Benzodiazepine mit mittlerer Wirkungsdauer, der zur kurzzeitigen Behandlung von Angst- und Panikstörungen eingesetzt wird.

Alprazolam wirkt beruhigend und angstlösend. Es wird zur kurzzeitigen symptomatischen Behandlung von Angstzuständen und von Panikstörungen sowie zur Behandlung der Übelkeit bei einer Chemotherapie eingesetzt.[5]

Alprazolam wird im Rahmen der Therapie von Depressionen[6] bzw. als Behandlung von Begleit-Depressionen bei Angstzuständen[7] verwendet. Es zeigt bei akuten oder Kurzzeitbehandlungen antidepressive Eigenschaften.[8]

Die Anwendung als Schlafmittel ist zwar häufig, allerdings hat Alprazolam dafür keine Indikation (Off-Label-Use).

Die Dosierung und die Dauer der Anwendung werden an die individuelle Reaktionslage, das Indikationsgebiet und die Schwere der Erkrankung angepasst. Hierbei gilt der Grundsatz, die Dosis so gering und die Behandlungsdauer so kurz wie möglich zu halten, um die Gefahr einer psychischen und physischen Abhängigkeit zu minimieren. Es wird empfohlen, die Gesamtdauer – einschließlich der Ausschleichphase – acht bis zwölf Wochen nicht übersteigen zu lassen.[6][9] Der Patient sollte außerdem in regelmäßigen Abständen untersucht werden, um die Notwendigkeit einer fortgesetzten Behandlung zu überprüfen. Um Entzugserscheinungen beim Absetzen von Alprazolam zu vermeiden, wird die Dosis langsam reduziert.

Die Anwendung von Alprazolam bei folgenden Erkrankungen ist problematisch:[6][7][9]

Alkohol kann die Wirkung von Alprazolam in nicht vorhersehbarer Weise verändern.

Bei gleichzeitiger Anwendung von Alprazolam mit folgenden Arzneimitteln kann es zu gegenseitiger Verstärkung der zentraldämpfenden Wirkung kommen:

Arzneimittel, welche über das Cytochrom P450 3A4 abgebaut werden, können die Konzentration und Wirksamkeit von Alprazolam erhöhen.

Die gleichzeitige Verabreichung von Ketoconazol, Itraconazol oder anderen Antimykotika vom Azol-Typ ist kontraindiziert.

Wechselwirkungen zwischen HIV-Protease-Inhibitoren (z. B. Ritonavir) und Alprazolam sind komplex und zeitabhängig. Niedrige Dosen von Ritonavir führen zu einer deutlichen Einschränkung der Alprazolam-Clearance, was dessen Halbwertszeit verlängert und die klinische Wirksamkeit erhöht. Allerdings hebt die CYP3A-Induktion diese Hemmung bei längerer Anwendungsdauer von Ritonavir wieder auf. Die Interaktion erfordert entweder eine Dosisreduktion oder ein Absetzen von Alprazolam.

Probleme können bei der gleichzeitigen Einnahme von folgenden Medikamenten auftreten:

Alprazolam darf nicht während der Schwangerschaft verwendet werden. Frauen im gebärfähigen Alter wird geraten, die Medikation abzusetzen, wenn sie schwanger sind oder die Absicht haben, schwanger zu werden. Wenn eine Verabreichung des Präparates in der Spätphase der Schwangerschaft oder hochdosiert während der Geburtswehen aus dringenden medizinischen Gründen unumgänglich ist, muss mit nachteiligen Wirkungen auf das Neugeborene gerechnet werden. Diese können Hypotonie, Ateminsuffizienz, Hypothermie, herabgesetzte Muskelspannung und Trinkschwäche (floppy infant syndrome) umfassen.[6][9]

Da Alprazolam in die Muttermilch übergeht und dort kumuliert, soll das Präparat während des Stillens nicht verabreicht werden. Neugeborene metabolisieren Benzodiazepine wesentlich langsamer als Erwachsene.[6][9]

Die Wirksamkeit und Unbedenklichkeit von Alprazolam bei Kindern und Jugendlichen unter 18 Jahren wurde nicht untersucht.[7]

Die häufigsten Nebenwirkungen sind Somnolenz und Benommenheit/Schwindel. Weiterhin können folgende Nebenwirkungen auftreten, insbesondere zu Beginn der Therapie: verringerte Aufmerksamkeit, Müdigkeit, gedämpfte Emotionen, Verwirrtheit, Muskelschwäche, Ataxie, Bewegungs- und Gangunsicherheit (Sturzgefahr besonders bei älteren Patienten), Tremor, Kopfschmerzen, Sehstörungen, Störungen des vegetativen Nervensystems (Gewichtsänderung, gastrointestinale Störungen, Blasenfunktionsstörungen). In der Regel verringern sich diese Symptome bei wiederholter Anwendung.

Weiterhin wurden Anorexie, Hyperprolaktinämie, Menstruationsstörungen und Störungen der Leberfunktion (z. B. Gelbsucht) beobachtet. Über Änderungen der Libido und Hautreaktionen wurde gelegentlich berichtet. Selten kann es zu einer Atemdepression kommen, insbesondere während der Nacht.

Es wird Patienten, die Alprazolam einnehmen, nicht empfohlen, Auto zu fahren, komplexe Maschinen zu bedienen oder andere potenziell gefährliche Tätigkeiten auszuführen, solange nicht bekannt ist, ob die Fähigkeit zur Ausübung solcher Tätigkeiten beeinträchtigt wird.[7]

Mit der Dauer der Einnahme von Alprazolam über mehrere Wochen kann es durch eine Toleranzentwicklung zum Nachlassen der Wirkung kommen.

Wie alle Benzodiazepine kann auch Alprazolam schon nach kurzer Einnahmedauer zu einer psychischen und körperlichen Abhängigkeit führen. Das Risiko für eine Sucht steigt mit der Höhe der Dosierung und der Länge der Medikamenteneinnahme. Patienten mit bekannten Tablettenabhängigkeit, Drogen- oder Alkoholsucht in der Vorgeschichte haben ein erhöhtes Risiko der Suchtentwicklung.

Wurde eine physische Abhängigkeit von Alprazolam entwickelt, löst ein abruptes Absetzen des Arzneimittels Entzugserscheinungen, wie z. B. Kopf- und Muskelschmerzen, Angstzustände, Spannung, Unruhe, Verstörtheit und Reizbarkeit aus. In schweren Fällen können Realitätsverlust, Persönlichkeitsverlust, Hyperacusis, Taubheitsgefühl und Kribbeln in den Extremitäten, Überempfindlichkeitsreaktionen auf Licht, Lärm und körperlichen Kontakt, Halluzinationen oder epileptische Anfälle auftreten. Die häufigen Entzugserscheinungen nach einer Alprazolam-Therapie sind in der Literatur gut dokumentiert.[10]

Nach dem Absetzen der Medikation kann es auch zum Auftreten eines sogenannten Rebound-Phänomenen kommen. Hier treten die Symptome, die zu einer Behandlung mit Benzodiazepinen führten, in verstärkter Form wieder auf. Als Begleitreaktionen sind Stimmungswechsel, Angstzustände und Unruhe möglich. Da nach einem abrupten Absetzen der Medikation die Entzugserscheinungen häufiger auftreten, ist eine schrittweise Reduktion der Dosierung empfohlen.[6][7][9]

Eine Überdosierung von Alprazolam führt zu einer allgemeinen zentralnervösen Dämpfung, die von Benommenheit bis hin zum Koma reichen kann. Durch die alleinige Einnahme von Alprazolam besteht im Allgemeinen keine Lebensgefahr, es sei denn in Kombination mit anderen zentral wirksamen Substanzen oder Alkohol; hierdurch kann es zum Atemstillstand kommen und eine Unterstützung der Vitalfunktionen nötig werden.

Zur Entgiftung kann bei bewusstseinsklaren Patienten Erbrechen herbeigeführt werden bzw. nach Intubation eine Magenspülung und Behandlung mit Aktivkohle durchgeführt werden. Die Behandlung mit Flumazenil als Antidot kann in Erwägung gezogen werden. Eine forcierte Diurese oder Dialysebehandlung ist dagegen wirkungslos.[7]

Alprazolam bindet im Gehirn an GABA-Rezeptoren und erhöht auf diese Weise die inhibitorischen Effekte des Neurotransmitters GABA.[7]

Neben unmetabolisiertem Alprazolam (ca. 20 %) werden als Hauptmetaboliten α-Hydroxyalprazolam (ca. 17 %) sowie 4-Hydroxyalprazolam ausgeschieden. Darüber hinaus sind eine Vielzahl weiterer Metabolite identifiziert worden. Die pharmakologische Aktivität von α-Hydroxyalprazolam beträgt ca. 50 %, verglichen mit Alprazolam. 4-Hydroxyalprazolam zeigt keine pharmakologische Aktivität. Die Halbwertszeit der beiden Hauptmetabolite liegt im gleichen Bereich wie die von Alprazolam. Die Metaboliten tragen aufgrund niedriger Konzentration wahrscheinlich kaum zum therapeutischen Effekt bei.

Alprazolam wird nach oraler Gabe rasch und gut resorbiert. Maximale Plasmaspiegel werden nach einmaliger oraler Gabe nach ein bis zwei Stunden erreicht. Die Bioverfügbarkeit liegt bei 80 %. Die Plasmaproteinbindung beträgt 70 bis 80 %. Das Verteilungsvolumen beträgt durchschnittlich 1,0 bis 1,2 l/kg und ist bei adipösen Patienten signifikant größer. Die Eliminationshalbwertszeit nach einmaliger Gabe liegt zwischen 12 und 15 Stunden. Bei älteren männlichen Patienten kann die Eliminationshalbwertzeit verlängert sein.

Die verzögerte Wirkstofffreisetzung der Retard-Tablette beeinflusst die Distribution, den Metabolismus und die Elimination von Alprazolam nicht. Die Serumspitzenkonzentrationen werden fünf bis elf Stunden nach der Gabe einer Retard-Tablette erreicht.[6][9]

Alprazolam tritt in verschiedenen Kristallformen auf. Mittels thermoanalytischer Untersuchungen und Röntgenbeugungsmessungen konnten zwei polymorphe Formen, ein Dihydrat und zwei nichtstöchiometrische Solvate mit Ethanol und Acetonitril charakterisiert werden.[2] Für das kommerzielle Polymorph I und das Dihydrat wurden die Kristallstrukturen bestimmt. Beide kristallieren in einem triklinen Gitter, das Polymorph I mit einer Raumgruppe P1 bzw. das Dihydrat mit der Raumgruppe P1.[2] Die Desolvatation des Dihydrates und des Ethanolsolvates ergeben das Polymorph I. Aus dem Acetonitrilsolvat resultiert das Polymorph II, welches mit 233 °C einen etwas höheren Schmelzpunkt besitzt.[2]

Alprazolam wurde durch die Firma Upjohn (später von Pfizer übernommen) entwickelt und 1984 unter dem Namen Tafil auf den deutschen Markt gebracht.[11] Sein Patentschutz endete im Jahre 1993.

Tafil (D), Xanax, Xanax retard (CH, USA), Xanor (A), zahlreiche Generika (D, A)[6][7][9]

Generic Name: alprazolam
Dosage Form: tablet, extended release

Medically reviewed by Drugs.com. Last updated on Apr 1, 2019.

Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death [see Warnings, Drug Interactions].

Xanax XR Tablets contain alprazolam which is a triazolo analog of the 1,4 benzodiazepine class of central nervous system-active compounds.

The chemical name of alprazolam is 8-chloro-1-methyl-6-phenyl-4H-s-triazolo [4,3-α] [1,4] benzodiazepine. The molecular formula is C17H13ClN4 which corresponds to a molecular weight of 308.76.

قرص xanax xr

The structural formula is represented below:

Alprazolam is a white crystalline powder, which is soluble in methanol or ethanol but which has no appreciable solubility in water at physiological pH.

CNS agents of the 1,4 benzodiazepine class presumably exert their effects by binding at stereospecific receptors at several sites within the central nervous system. Their exact mechanism of action is unknown. Clinically, all benzodiazepines cause a dose-related central nervous system depressant activity varying from mild impairment of task performance to hypnosis.

Following oral administration of XANAX (immediate-release) Tablets, alprazolam is readily absorbed. Peak concentrations in the plasma occur in one to two hours following administration. Plasma levels are proportional to the dose given; over the dose range of 0.5 to 3.0 mg, peak levels of 8.0 to 37 ng/mL were observed. Using a specific assay methodology, the mean plasma elimination half-life of alprazolam has been found to be about 11.2 hours (range: 6.3–26.9 hours) in healthy adults.

The mean absolute bioavailability of alprazolam from Xanax XR Tablets is approximately 90%, and the relative bioavailability compared to XANAX Tablets is 100%. The bioavailability and pharmacokinetics of alprazolam following administration of Xanax XR Tablets are similar to that for XANAX Tablets, with the exception of a slower rate of absorption. The slower absorption rate results in a relatively constant concentration that is maintained between 5 and 11 hours after the dosing. The pharmacokinetics of alprazolam and two of its major active metabolites (4-hydroxyalprazolam and α-hydroxyalprazolam) are linear, and concentrations are proportional up to the recommended maximum daily dose of 10 mg given once daily. Multiple dose studies indicate that the metabolism and elimination of alprazolam are similar for the immediate-release and the extended-release products.

Food has a significant influence on the bioavailability of Xanax XR Tablets. A high-fat meal given up to 2 hours before dosing with Xanax XR Tablets increased the mean Cmax by about 25%. The effect of this meal on Tmax depended on the timing of the meal, with a reduction in Tmax by about 1/3 for subjects eating immediately before dosing and an increase in Tmax by about 1/3 for subjects eating 1 hour or more after dosing. The extent of exposure (AUC) and elimination half-life (t1/2) were not affected by eating.

There were significant differences in absorption rate for the Xanax XR Tablet, depending on the time of day administered, with the Cmax increased by 30% and the Tmax decreased by an hour following dosing at night, compared to morning dosing.

The apparent volume of distribution of alprazolam is similar for Xanax XR and XANAX Tablets. In vitro, alprazolam is bound (80%) to human serum protein. Serum albumin accounts for the majority of the binding.

Alprazolam is extensively metabolized in humans, primarily by cytochrome P450 3A4 (CYP3A4), to two major metabolites in the plasma: 4-hydroxyalprazolam and α-hydroxyalprazolam. A benzophenone derived from alprazolam is also found in humans. Their half-lives appear to be similar to that of alprazolam. The pharmacokinetic parameters at steady-state for the two hydroxylated metabolites of alprazolam (4-hydroxyalprazolam and α-hydroxyalprazolam) were similar for XANAX and Xanax XR Tablets, indicating that the metabolism of alprazolam is not affected by absorption rate. The plasma concentrations of 4-hydroxyalprazolam and α-hydroxyalprazolam relative to unchanged alprazolam concentration after both Xanax XR and XANAX Tablets were always less than 10% and 4%, respectively. The reported relative potencies in benzodiazepine receptor binding experiments and in animal models of induced seizure inhibition are 0.20 and 0.66, respectively, for 4-hydroxyalprazolam and α-hydroxyalprazolam. Such low concentrations and the lesser potencies of 4-hydroxyalprazolam and α-hydroxyalprazolam suggest that they are unlikely to contribute much to the pharmacological effects of alprazolam. The benzophenone metabolite is essentially inactive.

Alprazolam and its metabolites are excreted primarily in the urine. The mean plasma elimination half-life of alprazolam following administration of Xanax XR Tablet ranges from 10.7–15.8 hours in healthy adults.

While pharmacokinetic studies have not been performed in special populations with Xanax XR Tablets, the factors (such as age, gender, hepatic or renal impairment) that would affect the pharmacokinetics of alprazolam after the administration of XANAX Tablets would not be expected to be different with the administration of Xanax XR Tablets.

Changes in the absorption, distribution, metabolism, and excretion of benzodiazepines have been reported in a variety of disease states including alcoholism, impaired hepatic function, and impaired renal function. Changes have also been demonstrated in geriatric patients. A mean half-life of alprazolam of 16.3 hours has been observed in healthy elderly subjects (range: 9.0–26.9 hours, n=16) compared to 11.0 hours (range: 6.3–15.8 hours, n=16) in healthy adult subjects. In patients with alcoholic liver disease the half-life of alprazolam ranged between 5.8 and 65.3 hours (mean: 19.7 hours, n=17) as compared to between 6.3 and 26.9 hours (mean=11.4 hours, n=17) in healthy subjects. In an obese group of subjects the half-life of alprazolam ranged between 9.9 and 40.4 hours (mean=21.8 hours, n=12) as compared to between 6.3 and 15.8 hours (mean=10.6 hours, n=12) in healthy subjects.

Because of its similarity to other benzodiazepines, it is assumed that alprazolam undergoes transplacental passage and that it is excreted in human milk.

Maximal concentrations and half-life of alprazolam are approximately 15% and 25% higher in Asians compared to Caucasians.

The pharmacokinetics of alprazolam after administration of the Xanax XR Tablet in pediatric patients have not been studied.

Gender has no effect on the pharmacokinetics of alprazolam.

Alprazolam concentrations may be reduced by up to 50% in smokers compared to non-smokers.

Alprazolam is primarily eliminated by metabolism via cytochrome P450 3A (CYP3A). Most of the interactions that have been documented with alprazolam are with drugs that inhibit or induce CYP3A4.

Compounds that are potent inhibitors of CYP3A would be expected to increase plasma alprazolam concentrations. Drug products that have been studied in vivo, along with their effect on increasing alprazolam AUC, are as follows: ketoconazole, 3.98 fold; itraconazole, 2.70 fold; nefazodone, 1.98 fold; fluvoxamine, 1.96 fold; and erythromycin, 1.61 fold (see CONTRAINDICATIONS, WARNINGS, and PRECAUTIONS–Drug Interactions).

CYP3A inducers would be expected to decrease alprazolam concentrations and this has been observed in vivo. The oral clearance of alprazolam (given in a 0.8 mg single dose) was increased from 0.90±0.21 mL/min/kg to 2.13±0.54 mL/min/kg and the elimination t1/2 was shortened (from 17.1±4.9 to 7.7 ±1.7 h) following administration of 300 mg/day carbamazepine for 10 days (see PRECAUTIONS–Drug Interactions). However, the carbamazepine dose used in this study was fairly low compared to the recommended doses (1000–1200 mg/day); the effect at usual carbamazepine doses is unknown.

Interactions involving HIV protease inhibitors (eg, ritonavir) and alprazolam are complex and time dependent. Short-term low doses of ritonavir (4 doses of 200 mg) reduced alprazolam clearance to 41% of control values, prolonged its elimination half-life (mean values, 30 versus 13 h) and enhanced clinical effects. However, upon extended exposure to ritonavir (500 mg, twice daily), CYP3A induction offset this inhibition. Alprazolam AUC and Cmax was reduced by 12% and 16%, respectively, in the presence of ritonavir (see WARNINGS).

The ability of alprazolam to induce or inhibit human hepatic enzyme systems has not been determined. However, this is not a property of benzodiazepines in general. Further, alprazolam did not affect the prothrombin or plasma warfarin levels in male volunteers administered sodium warfarin orally.

The efficacy of Xanax XR Tablets in the treatment of panic disorder was established in two 6-week, placebo-controlled studies of Xanax XR in patients with panic disorder.

In two 6-week, flexible-dose, placebo-controlled studies in patients meeting DSM-III criteria for panic disorder, patients were treated with Xanax XR in a dose range of 1 to 10 mg/day, on a once-a-day basis. The effectiveness of Xanax XR was assessed on the basis of changes in various measures of panic attack frequency, on various measures of the Clinical Global Impression, and on the Overall Phobia Scale. In all, there were seven primary efficacy measures in these studies, and Xanax XR was superior to placebo on all seven outcomes in both studies. The mean dose of Xanax XR at the last treatment visit was 4.2 mg/day in the first study and 4.6 mg/day in the second.

In addition, there were two 8-week, fixed-dose, placebo-controlled studies of Xanax XR in patients with panic disorder, involving fixed Xanax XR doses of 4 and 6 mg/day, on a once-a-day basis, that did not show a benefit for either dose of Xanax XR.

The longer-term efficacy of Xanax XR in panic disorder has not been systematically evaluated.

Analyses of the relationship between treatment outcome and gender did not suggest any differential responsiveness on the basis of gender.

Xanax XR Tablets are indicated for the treatment of panic disorder, with or without agoraphobia.

This claim is supported on the basis of two positive studies with Xanax XR conducted in patients whose diagnoses corresponded closely to the DSM-III-R/IV criteria for panic disorder (see CLINICAL EFFICACY TRIALS).

Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, ie, a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes.

The longer-term efficacy of Xanax XR has not been systematically evaluated. Thus, the physician who elects to use this drug for periods longer than 8 weeks should periodically reassess the usefulness of the drug for the individual patient.

Xanax XR Tablets are contraindicated in patients with known sensitivity to this drug or other benzodiazepines.

Xanax XR is contraindicated with ketoconazole and itraconazole, since these medications significantly impair the oxidative metabolism mediated by cytochrome P450 3A (CYP3A) (see CLINICAL PHARMACOLOGY, WARNINGS and PRECAUTIONS–Drug Interactions).

Concomitant use of benzodiazepines, including Xanax XR, and opioids may result in profound sedation, respiratory depression, coma, and death. Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.

قرص xanax xr

Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioids alone. If a decision is made to prescribe Xanax XR concomitantly with opioids, prescribe the lowest effective dosages and minimum durations of concomitant use, and follow patients closely for signs and symptoms of respiratory depression and sedation. In patients already receiving an opioid analgesic, prescribe a lower initial dose of Xanax XR than indicated in the absence of an opioid and titrate based on clinical response. If an opioid is initiated in a patient already taking Xanax XR, prescribe a lower initial dose of the opioid and titrate based upon clinical response.

Advise both patients and caregivers about the risks of respiratory depression and sedation when Xanax XR is used with opioids. Advise patients not to drive or operate heavy machinery until the effects of concomitant use with the opioid have been determined (see Drug Interactions).

Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to alprazolam. These include a spectrum of withdrawal symptoms; the most important is seizure (see DRUG ABUSE AND DEPENDENCE). Even after relatively short-term use at doses of ≤ 4 mg/day, there is some risk of dependence. Spontaneous reporting system data suggest that the risk of dependence and its severity appear to be greater in patients treated with doses greater than 4 mg/day and for long periods (more than 12 weeks). However, in a controlled postmarketing discontinuation study of panic disorder patients who received XANAX Tablets, the duration of treatment (3 months compared to 6 months) had no effect on the ability of patients to taper to zero dose. In contrast, patients treated with doses of XANAX Tablets greater than 4 mg/day had more difficulty tapering to zero dose than those treated with less than 4 mg/day.

Relapse or return of illness was defined as a return of symptoms characteristic of panic disorder (primarily panic attacks) to levels approximately equal to those seen at baseline before active treatment was initiated. Rebound refers to a return of symptoms of panic disorder to a level substantially greater in frequency, or more severe in intensity than seen at baseline. Withdrawal symptoms were identified as those which were generally not characteristic of panic disorder and which occurred for the first time more frequently during discontinuation than at baseline.

The rate of relapse, rebound, and withdrawal in patients with panic disorder who received Xanax XR Tablets has not been systematically studied. Experience in randomized placebo-controlled discontinuation studies of patients with panic disorder who received XANAX Tablets showed a high rate of rebound and withdrawal symptoms compared to placebo treated patients.

In a controlled clinical trial in which 63 patients were randomized to XANAX Tablets and where withdrawal symptoms were specifically sought, the following were identified as symptoms of withdrawal: heightened sensory perception, impaired concentration, dysosmia, clouded sensorium, paresthesias, muscle cramps, muscle twitch, diarrhea, blurred vision, appetite decrease, and weight loss. Other symptoms, such as anxiety and insomnia, were frequently seen during discontinuation, but it could not be determined if they were due to return of illness, rebound, or withdrawal.

In two controlled trials of 6 to 8 weeks duration where the ability of patients to discontinue medication was measured, 71%–93% of patients treated with XANAX Tablets tapered completely off therapy compared to 89%–96% of placebo treated patients. In a controlled postmarketing discontinuation study of panic disorder patients treated with XANAX Tablets, the duration of treatment (3 months compared to 6 months) had no effect on the ability of patients to taper to zero dose.

Seizures were reported for three patients in panic disorder clinical trials with Xanax XR. In two cases, the patients had completed 6 weeks of treatment with Xanax XR 6 mg/day before experiencing a single seizure. In one case, the patient abruptly discontinued Xanax XR, and in both cases, alcohol intake was implicated.The third case involved multiple seizures after the patient completed treatment with Xanax XR 4 mg/day and missed taking the medication on the first day of taper. All three patients recovered without sequelae.

Seizures have also been observed in association with dose reduction or discontinuation of XANAX Tablets, the immediate release form of alprazolam. Seizures attributable to XANAX were seen after drug discontinuance or dose reduction in 8 of 1980 patients with panic disorder or in patients participating in clinical trials where doses of XANAX greater than 4 mg/day for over 3 months were permitted. Five of these cases clearly occurred during abrupt dose reduction, or discontinuation from daily doses of 2 to 10 mg. Three cases occurred in situations where there was not a clear relationship to abrupt dose reduction or discontinuation. In one instance, seizure occurred after discontinuation from a single dose of 1 mg after tapering at a rate of 1 mg every three days from 6 mg daily. In two other instances, the relationship to taper is indeterminate; in both of these cases the patients had been receiving doses of 3 mg daily prior to seizure. The duration of use in the above 8 cases ranged from 4 to 22 weeks. There have been occasional voluntary reports of patients developing seizures while apparently tapering gradually from XANAX. The risk of seizure seems to be greatest 24–72 hours after discontinuation (see DOSAGE AND ADMINISTRATION for recommended tapering and discontinuation schedule).

The medical event voluntary reporting system shows that withdrawal seizures have been reported in association with the discontinuation of XANAX Tablets. In most cases, only a single seizure was reported; however, multiple seizures and status epilepticus were reported as well.

Early morning anxiety and emergence of anxiety symptoms between doses of XANAX Tablets have been reported in patients with panic disorder taking prescribed maintenance doses. These symptoms may reflect the development of tolerance or a time interval between doses which is longer than the duration of clinical action of the administered dose. In either case, it is presumed that the prescribed dose is not sufficient to maintain plasma levels above those needed to prevent relapse, rebound, or withdrawal symptoms over the entire course of the interdosing interval.

Withdrawal reactions may occur when dosage reduction occurs for any reason. This includes purposeful tapering, but also inadvertent reduction of dose (eg, the patient forgets, the patient is admitted to a hospital). Therefore, the dosage of Xanax XR should be reduced or discontinued gradually (see DOSAGE AND ADMINISTRATION).

Because of its CNS depressant effects, patients receiving Xanax XR should be cautioned against engaging in hazardous occupations or activities requiring complete mental alertness such as operating machinery or driving a motor vehicle. For the same reason, patients should be cautioned about the simultaneous ingestion of alcohol and other CNS depressant drugs during treatment with Xanax XR.

Benzodiazepines can potentially cause fetal harm when administered to pregnant women. If alprazolam is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Because of experience with other members of the benzodiazepine class, alprazolam is assumed to be capable of causing an increased risk of congenital abnormalities when administered to a pregnant woman during the first trimester. Because use of these drugs is rarely a matter of urgency, their use during the first trimester should almost always be avoided. The possibility that a woman of childbearing potential may be pregnant at the time of institution of therapy should be considered. Patients should be advised that if they become pregnant during therapy or intend to become pregnant they should communicate with their physicians about the desirability of discontinuing the drug.

The initial step in alprazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP3A). Drugs that inhibit this metabolic pathway may have a profound effect on the clearance of alprazolam. Consequently, alprazolam should be avoided in patients receiving very potent inhibitors of CYP3A. With drugs inhibiting CYP3A to a lesser but still significant degree, alprazolam should be used only with caution and consideration of appropriate dosage reduction. For some drugs, an interaction with alprazolam has been quantified with clinical data; for other drugs, interactions are predicted from in vitro data and/or experience with similar drugs in the same pharmacologic class.

The following are examples of drugs known to inhibit the metabolism of alprazolam and/or related benzodiazepines, presumably through inhibition of CYP3A.

Ketoconazole and itraconazole are potent CYP3A inhibitors and have been shown in vivo to increase plasma alprazolam concentrations 3.98 fold and 2.70 fold, respectively. The coadministration of alprazolam with these agents is not recommended. Other azole-type antifungal agents should also be considered potent CYP3A inhibitors and the coadministration of alprazolam with them is not recommended (see CONTRAINDICATIONS).

Coadministration of nefazodone increased alprazolam concentration two-fold.

Coadministration of fluvoxamine approximately doubled the maximum plasma concentration of alprazolam, decreased clearance by 49%, increased half-life by 71%, and decreased measured psychomotor performance.

Coadministration of cimetidine increased the maximum plasma concentration of alprazolam by 86%, decreased clearance by 42%, and increased half-life by 16%.

Interactions involving HIV protease inhibitors (eg, ritonavir) and alprazolam are complex and time dependent. Low doses of ritonavir resulted in a large impairment of alprazolam clearance, prolonged its elimination half-life and enhanced clinical effects. However, upon extended exposure to ritonavir, CYP3A induction offset this inhibition. This interaction will require a dose-adjustment or discontinuation of alprazolam.

Other drugs possibly affecting alprazolam metabolism by inhibition of CYP3A are discussed in the PRECAUTIONS section (see PRECAUTIONS–Drug Interactions).

As with other psychotropic medications, the usual precautions with respect to administration of the drug and size of the prescription are indicated for severely depressed patients or those in whom there is reason to expect concealed suicidal ideation or plans. Panic disorder has been associated with primary and secondary major depressive disorders and increased reports of suicide among untreated patients.

Episodes of hypomania and mania have been reported in association with the use of XANAX Tablets in patients with depression.

Alprazolam has a weak uricosuric effect. Although other medications with weak uricosuric effect have been reported to cause acute renal failure, there have been no reported instances of acute renal failure attributable to therapy with alprazolam.

It is recommended that the dosage be limited to the smallest effective dose to preclude the development of ataxia or oversedation which may be a particular problem in elderly or debilitated patients (see DOSAGE AND ADMINISTRATION). The usual precautions in treating patients with impaired renal, hepatic, or pulmonary function should be observed. There have been rare reports of death in patients with severe pulmonary disease shortly after the initiation of treatment with XANAX Tablets. A decreased systemic alprazolam elimination rate (eg, increased plasma half-life) has been observed in both alcoholic liver disease patients and obese patients receiving XANAX Tablets (see CLINICAL PHARMACOLOGY).

To assure safe and effective use of Xanax XR, the physician should provide the patient with the following guidance.

Laboratory tests are not ordinarily required in otherwise healthy patients. However, when treatment is protracted, periodic blood counts, urinalysis, and blood chemistry analyses are advisable in keeping with good medical practice.

The concomitant use of benzodiazepines and opioids increases the risk of respiratory depression because of actions at different receptor sites in the CNS that control respiration. Benzodiazepines interact at GABAA sites and opioids interact primarily at mu receptors. When benzodiazepines and opioids are combined, the potential for benzodiazepines to significantly worsen opioid-related respiratory depression exists. Limit dosage and duration of concomitant use of benzodiazepines and opioids, and monitor patients closely for respiratory depression and sedation.

If Xanax XR Tablets are to be combined with other psychotropic agents or anticonvulsant drugs, careful consideration should be given to the pharmacology of the agents to be employed, particularly with compounds which might potentiate the action of benzodiazepines. The benzodiazepines, including alprazolam, produce additive CNS depressant effects when coadministered with other psychotropic medications, anticonvulsants, antihistaminics, ethanol and other drugs which themselves produce CNS depression.

Increased digoxin concentrations have been reported when alprazolam was given, especially in elderly (>65 years of age). Patients who receive alprazolam and digoxin should therefore be monitored for signs and symptoms related to digoxin toxicity.

The steady state plasma concentrations of imipramine and desipramine have been reported to be increased an average of 31% and 20%, respectively, by the concomitant administration of XANAX Tablets in doses up to 4 mg/day. The clinical significance of these changes is unknown.

The initial step in alprazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP3A). Drugs which inhibit this metabolic pathway may have a profound effect on the clearance of alprazolam (see CONTRAINDICATIONS and WARNINGS for additional drugs of this type).

Coadministration of fluoxetine with alprazolam increased the maximum plasma concentration of alprazolam by 46%, decreased clearance by 21%, increased half-life by 17%, and decreased measured psychomotor performance.

Coadministration of propoxyphene decreased the maximum plasma concentration of alprazolam by 6%, decreased clearance by 38%, and increased half-life by 58%.

Coadministration of oral contraceptives increased the maximum plasma concentration of alprazolam by 18%, decreased clearance by 22%, and increased half-life by 29%.

Available data from clinical studies of benzodiazepines other than alprazolam suggest a possible drug interaction with alprazolam for the following: diltiazem, isoniazid, macrolide antibiotics such as erythromycin and clarithromycin, and grapefruit juice. Data from in vitro studies of alprazolam suggest a possible drug interaction with alprazolam for the following: sertraline and paroxetine. However, data from an in vivo drug interaction study involving a single dose of alprazolam 1 mg and steady state doses of sertraline (50 to 150 mg/day) did not reveal any clinically significant changes in the pharmacokinetics of alprazolam. Data from in vitro studies of benzodiazepines other than alprazolam suggest a possible drug interaction for the following: ergotamine, cyclosporine, amiodarone, nicardipine, and nifedipine. Caution is recommended during the coadministration of any of these with alprazolam (see WARNINGS).

Carbamazepine can increase alprazolam metabolism and therefore can decrease plasma levels of alprazolam.

Although interactions between benzodiazepines and commonly employed clinical laboratory tests have occasionally been reported, there is no consistent pattern for a specific drug or specific test.

No evidence of carcinogenic potential was observed during 2-year bioassay studies of alprazolam in rats at doses up to 30 mg/kg/day (150 times the maximum recommended daily human dose of 10 mg/day) and in mice at doses up to 10 mg/kg/day (50 times the maximum recommended daily human dose).

Alprazolam was not mutagenic in the rat micronucleus test at doses up to 100 mg/kg, which is 500 times the maximum recommended daily human dose of 10 mg/day. Alprazolam also was not mutagenic in vitro in the DNA Damage/Alkaline Elution Assay or the Ames Assay.

Alprazolam produced no impairment of fertility in rats at doses up to 5 mg/kg/day, which is 25 times the maximum recommended daily human dose of 10 mg/day.

(see WARNINGS section).

It should be considered that the child born of a mother who is receiving benzodiazepines may be at some risk for withdrawal symptoms from the drug during the postnatal period. Also, neonatal flaccidity and respiratory problems have been reported in children born of mothers who have been receiving benzodiazepines.

Alprazolam has no established use in labor or delivery.

Benzodiazepines are known to be excreted in human milk. It should be assumed that alprazolam is as well. Chronic administration of diazepam to nursing mothers has been reported to cause their infants to become lethargic and to lose weight. As a general rule, nursing should not be undertaken by mothers who must use alprazolam.

Safety and effectiveness of alprazolam in individuals below 18 years of age have not been established.

The elderly may be more sensitive to the effects of benzodiazepines. They exhibit higher plasma alprazolam concentrations due to reduced clearance of the drug as compared with a younger population receiving the same doses. The smallest effective dose of alprazolam should be used in the elderly to preclude the development of ataxia and oversedation (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

The information included in the subsection on Adverse Events Observed in Short-Term, Placebo-Controlled Trials with Xanax XR Tablets is based on pooled data of five 6- and 8-week placebo-controlled clinical studies in panic disorder.

Adverse event reports were elicited either by general inquiry or by checklist, and were recorded by clinical investigators using terminology of their own choosing. The stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse event of the type listed. An event was considered treatment emergent if it occurred for the first time or worsened during therapy following baseline evaluation. In the tables and tabulations that follow, standard MedDRA terminology (version 4.0) was used to classify reported adverse events.

Approximately 17% of the 531 patients who received Xanax XR in placebo-controlled clinical trials for panic disorder had at least one adverse event that led to discontinuation compared to 8% of 349 placebo-treated patients. The most common events leading to discontinuation and considered to be drug-related (ie, leading to discontinuation in at least 1% of the patients treated with Xanax XR at a rate at least twice that of placebo) are shown in the following table.

The prescriber should be aware that adverse event incidence cannot be used to predict the incidence of adverse events in the course of usual medical practice where patient characteristics and other factors differ from those which prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with event incidence obtained from other clinical investigations involving different treatments, uses, and investigators. The cited values, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and non-drug factors to the adverse event incidence rate in the population studied.

The following table shows the incidence of treatment-emergent adverse events that occurred during 6- to 8-week placebo-controlled trials in 1% or more of patients treated with Xanax XR where the incidence in patients treated with Xanax XR was greater than the incidence in placebo-treated patients. The most commonly observed adverse events in panic disorder patients treated with Xanax XR (incidence of 5% or greater and at least twice the incidence in placebo patients) were: sedation, somnolence, memory impairment, dysarthria, coordination abnormal, ataxia, libido decreased (see table).

Following is a list of MedDRA terms that reflect treatment-emergent adverse events reported by 531 patients with panic disorder treated with Xanax XR. All potentially important reported events are included except those already listed in the above table or elsewhere in labeling, those events for which a drug cause was remote, those event terms that were so general as to be uninformative, and those events that occurred at rates similar to background rates in the general population. It is important to emphasize that, although the events reported occurred during treatment with Xanax XR, they were not necessarily caused by the drug. Events are further categorized by body system and listed in order of decreasing frequency according to the following definitions: frequent adverse events are those occurring on 1 or more occasions in at least l/l00 patients; infrequent adverse events are those occurring in less than l/100 patients but at least l/1000 patients; rare events are those occurring in fewer than l/1000 patients.

Cardiac disorders: Frequent: palpitation; Infrequent: sinus tachycardia

Ear and Labyrinth disorders: Frequent: Vertigo; Infrequent: tinnitus, ear pain

Eye disorders: Frequent: blurred vision; Infrequent: mydriasis, photophobia

Gastrointestinal disorders: Frequent: diarrhea, vomiting, dyspepsia, abdominal pain; Infrequent: dysphagia, salivary hypersecretion

General disorders and administration site conditions: Frequent: malaise, weakness, chest pains; Infrequent: fall, pyrexia, thirst, feeling hot and cold, edema, feeling jittery, sluggishness, asthenia, feeling drunk, chest tightness, increased energy, feeling of relaxation, hangover, loss of control of legs, rigors

Musculoskeletal and connective tissue disorders: Frequent: back pain, muscle cramps, muscle twitching

Nervous system disorders: Frequent: headache, dizziness, tremor; Infrequent: amnesia, clumsiness, syncope, hypotonia, seizures, depressed level of consciousness, sleep apnea syndrome, sleep talking, stupor

Psychiatric system disorders: Frequent: irritability, insomnia, nervousness, derealization, libido increased, restlessness, agitation, depersonalization, nightmare; Infrequent: abnormal dreams, apathy, aggression, anger, bradyphrenia, euphoric mood, logorrhea, mood swings, dysphonia, hallucination, homicidal ideation, mania, hypomania, impulse control, psychomotor retardation, suicidal ideation

Renal and urinary disorders: Frequent: difficulty in micturition; Infrequent: urinary frequency, urinary incontinence

Respiratory, thoracic, and mediastinal disorders: Frequent: nasal congestion, hyperventilation; Infrequent: choking sensation, epistaxis, rhinorrhea

Skin and subcutaneous tissue disorders: Frequent: sweating increased; Infrequent: clamminess, rash, urticaria

Vascular disorders: Infrequent: hypotension

The categories of adverse events reported in the clinical development program for XANAX Tablets in the treatment of panic disorder differ somewhat from those reported for Xanax XR Tablets because the clinical trials with XANAX Tablets and Xanax XR Tablets used different standard medical nomenclature for reporting the adverse events. Nevertheless, the types of adverse events reported in the clinical trials with XANAX Tablets were generally the same as those reported in the clinical trials with Xanax XR Tablets.

The following table shows the incidence of discontinuation-emergent adverse events that occurred during short-term, placebo-controlled trials in 5% or more of patients treated with Xanax XR where the incidence in patients treated with Xanax XR was two times greater than the incidence in placebo-treated patients.

There have also been reports of withdrawal seizures upon rapid decrease or abrupt discontinuation of alprazolam (see WARNINGS).

To discontinue treatment in patients taking Xanax XR Tablets, the dosage should be reduced slowly in keeping with good medical practice. It is suggested that the daily dosage of Xanax XR Tablets be decreased by no more than 0.5 mg every three days (see DOSAGE AND ADMINISTRATION). Some patients may benefit from an even slower dosage reduction. In a controlled postmarketing discontinuation study of panic disorder patients which compared this recommended taper schedule with a slower taper schedule, no difference was observed between the groups in the proportion of patients who tapered to zero dose; however, the slower schedule was associated with a reduction in symptoms associated with a withdrawal syndrome.

As with all benzodiazepines, paradoxical reactions such as stimulation, increased muscle spasticity, sleep disturbances, hallucinations, and other adverse behavioral effects such as agitation, rage, irritability, and aggressive or hostile behavior have been reported rarely. In many of the spontaneous case reports of adverse behavioral effects, patients were receiving other CNS drugs concomitantly and/or were described as having underlying psychiatric conditions. Should any of the above events occur, alprazolam should be discontinued. Isolated published reports involving small numbers of patients have suggested that patients who have borderline personality disorder, a prior history of violent or aggressive behavior, or alcohol or substance abuse may be at risk for such events. Instances of irritability, hostility, and intrusive thoughts have been reported during discontinuation of alprazolam in patients with posttraumatic stress disorder.

Various adverse drug reactions have been reported in association with the use of XANAX Tablets since market introduction. The majority of these reactions were reported through the medical event voluntary reporting system. Because of the spontaneous nature of the reporting of medical events and the lack of controls, a causal relationship to the use of XANAX Tablets cannot be readily determined. Reported events include: gastrointestinal disorder, hypomania, mania, liver enzyme elevations, hepatitis, jaundice, hepatic failure, Stevens-Johnson syndrome, photosensitivity reaction, angioedema, peripheral edema, menstruation irregular, hyperprolactinemia, gynecomastia, and galactorrhea (see PRECAUTIONS).

Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazepines, including alprazolam. The symptoms can range from mild dysphoria and insomnia to a major syndrome that may include abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions. Distinguishing between withdrawal emergent signs and symptoms and the recurrence of illness is often difficult in patients undergoing dose reduction. The long-term strategy for treatment of these phenomena will vary with their cause and the therapeutic goal. When necessary, immediate management of withdrawal symptoms requires re-institution of treatment at doses of alprazolam sufficient to suppress symptoms. There have been reports of failure of other benzodiazepines to fully suppress these withdrawal symptoms. These failures have been attributed to incomplete cross-tolerance but may also reflect the use of an inadequate dosing regimen of the substituted benzodiazepine or the effects of concomitant medications.

While it is difficult to distinguish withdrawal and recurrence for certain patients, the time course and the nature of the symptoms may be helpful. A withdrawal syndrome typically includes the occurrence of new symptoms, tends to appear toward the end of taper or shortly after discontinuation, and will decrease with time. In recurring panic disorder, symptoms similar to those observed before treatment may recur either early or late, and they will persist.

While the severity and incidence of withdrawal phenomena appear to be related to dose and duration of treatment, withdrawal symptoms, including seizures, have been reported after only brief therapy with alprazolam at doses within the recommended range for the treatment of anxiety (eg, 0.75 to 4 mg/day). Signs and symptoms of withdrawal are often more prominent after rapid decrease of dosage or abrupt discontinuance. The risk of withdrawal seizures may be increased at doses above 4 mg/day (see WARNINGS).

Patients, especially individuals with a history of seizures or epilepsy, should not be abruptly discontinued from any CNS depressant agent, including alprazolam. It is recommended that all patients on alprazolam who require a dosage reduction be gradually tapered under close supervision (see WARNINGS and DOSAGE AND ADMINISTRATION).

Psychological dependence is a risk with all benzodiazepines, including alprazolam. The risk of psychological dependence may also be increased at doses greater than 4 mg/day and with longer term use, and this risk is further increased in patients with a history of alcohol or drug abuse. Some patients have experienced considerable difficulty in tapering and discontinuing from alprazolam, especially those receiving higher doses for extended periods. Addiction-prone individuals should be under careful surveillance when receiving alprazolam. As with all anxiolytics, repeat prescriptions should be limited to those who are under medical supervision.

Alprazolam is a controlled substance under the Controlled Substance Act by the Drug Enforcement Administration and Xanax XR Tablets have been assigned to Schedule IV.

Overdosage reports with XANAX Tablets are limited. Manifestations of alprazolam overdosage include somnolence, confusion, impaired coordination, diminished reflexes, and coma. Death has been reported in association with overdoses of alprazolam by itself, as it has with other benzodiazepines. In addition, fatalities have been reported in patients who have overdosed with a combination of a single benzodiazepine, including alprazolam, and alcohol; alcohol levels seen in some of these patients have been lower than those usually associated with alcohol-induced fatality.

Animal experiments have suggested that forced diuresis or hemodialysis are probably of little value in treating overdosage.

As in all cases of drug overdosage, respiration, pulse rate, and blood pressure should be monitored. General supportive measures should be employed, along with immediate gastric lavage. Intravenous fluids should be administered and an adequate airway maintained. If hypotension occurs, it may be combated by the use of vasopressors. Dialysis is of limited value. As with the management of intentional overdosing with any drug, it should be borne in mind that multiple agents may have been ingested.

Flumazenil, a specific benzodiazepine receptor antagonist, is indicated for the complete or partial reversal of the sedative effects of benzodiazepines and may be used in situations when an overdose with a benzodiazepine is known or suspected. Prior to the administration of flumazenil, necessary measures should be instituted to secure airway, ventilation, and intravenous access. Flumazenil is intended as an adjunct to, not as a substitute for, proper management of benzodiazepine overdose. Patients treated with flumazenil should be monitored for re-sedation, respiratory depression, and other residual benzodiazepine effects for an appropriate period after treatment. The prescriber should be aware of a risk of seizure in association with flumazenil treatment, particularly in long-term benzodiazepine users and in cyclic antidepressant overdose. The complete flumazenil package insert including CONTRAINDICATIONS, WARNINGS, and PRECAUTIONS should be consulted prior to use.

Xanax XR Tablets may be administered once daily, preferably in the morning. The tablets should be taken intact; they should not be chewed, crushed, or broken.

The suggested total daily dose ranges between 3 to 6 mg/day. Dosage should be individualized for maximum beneficial effect. While the suggested total daily dosages given will meet the needs of most patients, there will be some patients who require doses greater than 6 mg/day. In such cases, dosage should be increased cautiously to avoid adverse effects.

In elderly patients, in patients with advanced liver disease, or in patients with debilitating disease, the usual starting dose of Xanax XR is 0.5 mg once daily. This may be gradually increased if needed and tolerated (see Dose Titration). The elderly may be especially sensitive to the effects of benzodiazepines.

Treatment with Xanax XR may be initiated with a dose of 0.5 mg to 1 mg once daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg/day. Slower titration to the dose levels may be advisable to allow full expression of the pharmacodynamic effect of Xanax XR.

Generally, therapy should be initiated at a low dose to minimize the risk of adverse responses in patients especially sensitive to the drug. Dose should be advanced until an acceptable therapeutic response (ie, a substantial reduction in or total elimination of panic attacks) is achieved, intolerance occurs, or the maximum recommended dose is attained.

In controlled trials conducted to establish the efficacy of Xanax XR Tablets in panic disorder, doses in the range of 1 to 10 mg/day were used. Most patients showed efficacy in the dose range of 3 to 6 mg/day. Occasional patients required as much as 10 mg/day to achieve a successful response.

The necessary duration of treatment for panic disorder patients responding to Xanax XR is unknown. However, periodic reassessment is advised. After a period of extended freedom from attacks, a carefully supervised tapered discontinuation may be attempted, but there is evidence that this may often be difficult to accomplish without recurrence of symptoms and/or the manifestation of withdrawal phenomena.

Because of the danger of withdrawal, abrupt discontinuation of treatment should be avoided (see WARNINGS, PRECAUTIONS, DRUG ABUSE AND DEPENDENCE).

In all patients, dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage. Although there are no systematically collected data to support a specific discontinuation schedule, it is suggested that the daily dosage be decreased by no more than 0.5 mg every three days. Some patients may require an even slower dosage reduction.

In any case, reduction of dose must be undertaken under close supervision and must be gradual. If significant withdrawal symptoms develop, the previous dosing schedule should be reinstituted and, only after stabilization, should a less rapid schedule of discontinuation be attempted. In a controlled postmarketing discontinuation study of panic disorder patients which compared this recommended taper schedule with a slower taper schedule, no difference was observed between the groups in the proportion of patients who tapered to zero dose; however, the slower schedule was associated with a reduction in symptoms associated with a withdrawal syndrome. It is suggested that the dose be reduced by no more than 0.5 mg every three days, with the understanding that some patients may benefit from an even more gradual discontinuation. Some patients may prove resistant to all discontinuation regimens.

Patients who are currently being treated with divided doses of XANAX (immediate-release) Tablets, for example 3 to 4 times a day, may be switched to Xanax XR Tablets at the same total daily dose taken once daily. If the therapeutic response after switching is inadequate, the dosage may be titrated as outlined above.

Xanax XR (extended-release) Tablets are available as follows:

0.5 mg (white, pentagonal-shaped tablets debossed with an “X” on one side and “0.5” on the other side)

1 mg (yellow, square-shaped tablets debossed with an “X” on one side and “1” on the other side)

2 mg (blue, round-shaped tablets debossed with an “X” on one side and “2” on the other side)

3 mg (green, triangular-shaped tablets debossed with an “X” on one side and “3” on the other side)

Store at 25°C (77°F); excursions permitted to 15–30°C (59–86°F) [see USP Controlled Room Temperature].

When rats were treated with alprazolam at 3, 10, and 30 mg/kg/day (15 to 150 times the maximum recommended human dose) orally for 2 years, a tendency for a dose related increase in the number of cataracts was observed in females and a tendency for a dose related increase in corneal vascularization was observed in males. These lesions did not appear until after 11 months of treatment.

This product’s label may have been updated. For current full prescribing information, please visit www.pfizer.com.

LAB-0006-8.0
December 2016

This Medication Guide has been approved by the U.S. Food and Drug Administration.

This product’s label may have been updated. For current full prescribing information, please visit www.pfizer.com

LAB-0824-1.0
December 2016

ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 0009-0057-07
Pfizer

Xanax XR®
CIV

alprazolam
extended-release tablets

0.5 mg

60 Tablets
Rx only

ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 0009-0059-07
Pfizer

Xanax XR®
CIV

alprazolam
extended-release tablets

1 mg

60 Tablets
Rx only

ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 0009-0066-07
Pfizer

Xanax XR®
CIV

alprazolam
extended-release tablets

2 mg

60 Tablets
Rx only

ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 0009-0068-07
Pfizer

Xanax XR®
CIV

alprazolam
extended-release tablets

3 mg

60 Tablets
Rx only

Medical Disclaimer

Other brands: Alprazolam Intensol, Niravam

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Alprazolam oral tablet is a prescription drug that’s available as the brand-name drugs Alprazolam Intensol, Xanax, or Xanax XR. It’s also available as a generic drug. Generic drugs usually cost less. In some cases, they may not be available in every strength or form as the brand-name version.

Alprazolam oral tablets come in immediate-release and extended-release forms, as well as an orally disintegrating form. Alprazolam also comes as a solution. All forms are taken by mouth.

An extended-release drug is released slowly into the bloodstream over time. An immediate-release drug is released into the bloodstream more quickly. The extended-release drug is only used to treat panic disorder.

This drug is used to manage anxiety disorders or panic disorder. It can be used for the short-term relief of symptoms of anxiety, or anxiety linked with depression. Anxiety or tension caused by the stress of everyday life usually doesn’t need to be treated with this drug.

This drug may be used as part of a combination therapy. This means you may need to take it with other medications.

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This drug belongs to a class of drugs called benzodiazepines. A class of drugs is a group of medications that work in a similar way. These drugs are often used to treat similar conditions.

This drug attaches to certain benzodiazepine receptors in your brain and nervous system. This boosts the activity of a chemical called gamma-aminobutyric acid (GABA). This helps to produce a calming effect in your brain.

Alprazolam oral tablet can cause dizziness and drowsiness during the first few hours after you take it. Don’t drive a car or use dangerous machinery until you know how this drug affects you.

This drug can also cause other side effects.

The more common side effects of alprolazam oral tablet can include:

If these effects are mild, they may go away within a few days or a couple of weeks. If they’re more severe or don’t go away, talk to your doctor or pharmacist.

Call your doctor right away if you have serious side effects. Call 911 if your symptoms feel life-threatening or if you think you’re having a medical emergency. Serious side effects and their symptoms can include the following:

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs affect each person differently, we cannot guarantee that this information includes all possible side effects. This information is not a substitute for medical advice. Always discuss possible side effects with a healthcare provider who knows your medical history.

Alprazolam oral tablet can interact with other medications, vitamins, or herbs you may be taking. An interaction is when a substance changes the way a drug works. This can be harmful or prevent the drug from working well.

To help avoid interactions, your doctor should manage all of your medications carefully. Be sure to tell your doctor about all medications, vitamins, or herbs you’re taking. To find out how this drug might interact with something else you’re taking, talk to your doctor or pharmacist.

Do not take these drugs with Xanax. When used with Xanax, these drugs can cause dangerous effects in the body. Examples of these drugs include:

Taking alprazolam with certain medications raises your risk of side effects from those drugs. If you take one of these drugs with alprazolam, you may have increased drowsiness. These drugs include:

If you take one of these drugs with alprazolam, you may have increased drowsiness or other side effects.

When used with alprazolam, these drugs can make alprazolam less effective. This means it won’t work as well to treat your condition. This is because the amount of alprazolam in your body is decreased. Examples of these drugs include:

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs interact differently in each person, we cannot guarantee that this information includes all possible interactions. This information is not a substitute for medical advice. Always speak with your healthcare provider about possible interactions with all prescription drugs, vitamins, herbs and supplements, and over-the-counter drugs that you are taking.

This drug comes with several warnings.

This drug may cause a severe allergic reaction. Symptoms can include:

If you have an allergic reaction, call your doctor or local poison control center right away. If your symptoms are severe, call 911 or go to the nearest emergency room. Don’t take this drug again if you’ve ever had an allergic reaction to it. Taking it again could be fatal (cause death).

Alprazolam can cause drowsiness, dizziness, or lightheadedness. The use of drinks that contain alcohol raises your risk of these side effects. Try to avoid drinking alcohol while you take this drug.

For people with depression: If you have pre-existing depression, this drug may make your condition worse. If your depression gets worse or you have suicidal thoughts, call your doctor right away.

For people with acute narrow-angle glaucoma: This drug can make your condition worse. Do not take this drug if you have acute narrow-angle glaucoma.

For people with a history of alcoholism, drug abuse, or personality disorder: This drug can lead to physical and psychological dependence (addiction). If you have a history of these conditions, you have a greater risk of dependence on this drug.

For people with liver disease: It may be harder for your body to break down this drug. This can increase the amount of the drug in your body, which can lead to more side effects.

For people with obesity: It may be harder for your body to break down this drug. This can increase the amount of the drug in your body, which can lead to more side effects.

For people with severe lung disease: This drug can make your condition worse. Talk with your doctor about whether this drug is safe for you.

For pregnant women: This drug is a category D pregnancy drug. That means two things:

Talk to your doctor if you’re pregnant or planning to become pregnant. Ask your doctor to tell you about the specific harm that may be done to the fetus. This drug should be only used if the potential risk to the fetus is acceptable given the drug’s potential benefit.

For women who are breastfeeding: This drug may pass into breast milk and may cause side effects in a child who is breastfed. Your child may become lethargic (drowsy) and lose weight. Talk to your doctor if you breastfeed your child. You may need to decide whether to stop breastfeeding or stop taking this medication.

For seniors: If you’re over the age of 65 years, you may be more sensitive to the sedative side effects of this drug. This means you may be more likely to be drowsy. Your doctor should monitor you closely. Also, you should take extra care to avoid falls that may be caused by drowsiness or dizziness.

For children: This medication has not been studied in children. It should not be used in people younger than 18 years.

This dosage information is for alprazolam oral tablet. All possible dosages and drug forms may not be included here. Your dosage, drug form, and how often you take the drug will depend on:

Generic: Alprazolam

Brand: Xanax

Brand: Alprazolam Intensol

Adult dosage (ages 18–64 years)

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Immediate-release tablet, orally disintegrating tablet, or oral solution:

Child dosage (ages 0–17 years)

This medication has not been studied in children. It should not be used in people younger than 18 years.

Senior dosage (ages 65 years and older)

Immediate-release tablet, orally disintegrating tablet, or oral solution:

Special considerations

Generic: Alprazolam

Brand: Xanax

Brand: Xanax XR

Brand: Alprazolam Intensol

Adult dosage (ages 18–64 years)

Immediate-release tablet, orally disintegrating tablet, or oral solution:

Extended-release tablet:

Child dosage (ages 0–17 years)

This medication has not been studied in children. It should not be used in people younger than 18 years.

Senior dosage (ages 65 years and older)

Immediate-release tablet, orally disintegrating tablet, or oral solution:

Extended-release tablet:

Special considerations

Disclaimer: Our goal is to provide you with the most relevant and current information. However, because drugs affect each person differently, we cannot guarantee that this list includes all possible dosages. This information is not a substitute for medical advice. Always to speak with your doctor or pharmacist about dosages that are right for you.

This drug is used for short-term treatment. It comes with serious risks if you don’t take it as prescribed.

If you stop taking the drug suddenly or don’t take it at all: If you stop taking the drug suddenly, you may have significant withdrawal symptoms. These can include life-threatening symptoms, such as seizures. To avoid withdrawal, your doctor will decrease your dose slowly over time. If you don’t take this drug at all, your symptoms may not improve.

If you miss doses or don’t take the drug on schedule: Your medication may not work as well or may stop working completely. You may have withdrawal symptoms if you don’t take the drug on schedule.

If you take too much: You could have dangerous levels of the drug in your body. Symptoms of an overdose of this drug can include:

If you think you’ve taken too much of this drug, call your doctor or local poison control center. If your symptoms are severe, call 911 or go to the nearest emergency room right away.

What to do if you miss a dose: Take your dose as soon as you remember. But if you remember just a few hours before your next scheduled dose, take only one dose. Never try to catch up by taking two doses at once. This could result in dangerous side effects.

How to tell if the drug is working: You should have decreased symptoms of anxiety, or a decrease in panic attacks.

Keep these considerations in mind if your doctor prescribes alprazolam oral tablet for you.

A prescription for this medication is refillable. You should not need a new prescription for this medication to be refilled. Your doctor will write the number of refills authorized on your prescription.

When traveling with your medication:

You and your doctor should watch for any problems with your mental health or behavior. This drug can cause new mood and behavior problems, or worsen problems you already have.

Many insurance companies require a prior authorization for this drug. This means your doctor may need to get approval from your insurance company before your insurance company will pay for the prescription.

There are other drugs available to treat your condition. Some may be better suited for you than others. Talk to your doctor about other drug options that may work for you.

Disclaimer: Healthline has made every effort to make certain that all information is factually correct, comprehensive, and up-to-date. However, this article should not be used as a substitute for the knowledge and expertise of a licensed healthcare professional. You should always consult your doctor or other healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. The absence of warnings or other information for a given drug does not indicate that the drug or drug combination is safe, effective, or appropriate for all patients or all specific uses.

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