Alprazolam

(al - PR AY Z - o h- la m)

CLASSIFICATION(S): Antianxiety drug, benzodiazepine PREGNANCY CATEGORY: D Rx: Alprazolam Extended-Release, Alprazolam Intensol, Niravam, Xanax, Xanax XR, C-IV WRx: Apo-Alpraz, Apo-Alpraz TS, Gen-Alprazolam, Novo-Alprazol, NuAlpraz, Xanax TS, ratio-Alprazolam.
SEE ALSO TRANQUILIZERS/ ANTIMANIC DRUGS/ HYPNOTICS.

USES Immediate-Release Tablets, Orally Disintegrating Tablets and Intensol: (1) Anxiety. (2) Anxiety associated with depression with or without agoraphobia. Immediate- and Extended-Release Tablets, Orally Disintegrating Tablets: Panic disorder with or without agoraphobia. Investigational: Agoraphobia with social phobia, depression, PMS. ACTION/KINETICS Action Reduces anxiety by increasing or facilitating the inhibitory neurotransmitter activity of GABA. The skeletal muscle relaxant effect may be due to enhancement of GABA-mediated presynaptic inhibition at the spinal level as well as in the brain stem reticular formation. Pharmacokinetics Onset: Intermediate. Peak plasma lev1 els: PO, 837 ng/mL after 12 hr. t /2: 1215 hr. Sublingual absorption is as rapid as PO use; completeness of absorption is comparable. Metabolized to alpha-hydroxyalprazolam, an active me1 tabolite. t /2: 1215 hr. Excreted in urine. Plasma protein binding: 80%. CONTRAINDICATIONS Use with itraconazole or ketoconazole. Acute narrow-angle glaucoma. SIDE EFFECTS Most Common Drowsiness, ataxia, confusion. See Tranquilizers, Antimanic Drugs, and Hypnotics for a complete list of possible side effects.

ADDITIONAL DRUG INTERACTIONS Azole antifungal drugs, clarithromycin, erythromycin, protease inhibitors, or SSRIs decrease the metabolism of alprazolam. Decrease the dose of alprazolam by 50 to 75%. H Possible lethargy and disorientation when combined with kava kava. HOW SUPPLIED Oral Solution (Intensol): 1 mg/mL; Tablets, Extended-Release: 0.5 mg, 1 mg, 2 mg, 3 mg; Tablets, Immediate-Release: 0.25 mg, 0.5 mg, 1 mg, 2 mg; Tablets, Oral Disintegrating: 0.25 mg, 0.5 mg, 1 mg, 2 mg. DOSAGE ORAL SOLUTION; TABLETS, IMMEDIATE-RELEASE; TABLETS, ORAL DISINTEGRATING Anxiety disorders. Adults, initial: 0.250.5 mg 3 times per day; then, titrate to needs of client at intervals of 34 days in increments of no more than 1 mg/day, with total daily dosage not to exceed 4 mg. In elderly or debilitated, initial: 0.25 mg 23 times per day; then, adjust dosage to needs of client. TABLETS, EXTENDED-RELEASE; TABLETS, IMMEDIATE-RELEASE; TABLETS, ORAL DISINTEGRATING Panic disorders (use Niravam, Xanax, Xanax XR). Immediate-Release Tablets, Oral Disintegrating Tablets: Adults, initial: 0.5 mg 3 times per day; increase dose as needed, every 34 days in increments of no more than 1 mg/day up to a maximum of 10 mg/day (mean dose: 56 mg/day). Extended-Release Tablets: Adults, initial: 0.5 mg1 mg once daily. Total daily dose: 36 mg/day. Agoraphobia with social phobia. Adults: 28 mg/day. PMS. 0.25 mg 3 times per day.

NURSING CONSIDERATIONS
E Do not confuse alprazolam with lorazepam (anti-anxiety drug) or Xanax with Zantac (H-2 receptor blocker). ADMINISTRATION/STORAGE 1. Reduce dosage in elderly and debilitated clients. Starting dose of immediIV = Intravenous

C = see color insert

H = Herbal

E = sound alike drug

ALPRAZOLAM
4. Just before giving orally-disintegrating tablets, remove the tablet from the bottle with dry hands. Immediately place the tablet on top of the tongue where it will disintegrate and be swallowed with saliva. Giving with a liquid is not necessary. If only one-half of a scored tablet is used, discard the unused portion of the tablet immediately as it may not remain stable. Discard any cotton included in the bottle and reseal the bottle tightly to prevent introduction of moisture that may cause tablet disintegration. 5. May take tablets with milk or food to decrease GI upset. 6. Include extra fluids and bulk in the diet to minimize constipation. 7. Avoid activities that require mental alertness until tolerance assessed; may cause drowsiness or impair judgment, thinking, or reflexes. Rise slowly to prevent lightheadedness or fainting. 8. Seek appropriate psychological therapy as prolonged use may cause dependence. Provider will gradually taper dose (eg, no more than 0.5 mg every 3 days) when therapy no longer indicated. Report withdrawal symptoms (eg, increased anxiety, tremor, palpitations, muscle or abdominal cramps, sweating). If significant withdrawal symptoms develop, they may reinstitute previous dosing schedule and determine need for in house detoxification or a less rapid tapering regimen once stabilized as MI or death may occur in severe cases. 9. Use support devices as needed, especially at night; elderly tend to become confused. Store drug away from bedside to prevent overdose. 10. Avoid smoking, alcohol consumption, or any other CNS depressants without provider approval. Keep all F/U to evaluate response and adverse SE. OUTCOMES/EVALUATE Positive behaviors with phobias Anxiety/restlessness; control of panic disorder Treatment of irritable bowel syndrome, depression, PMS (unlabeled)

ate-release and intensol is 0.25 mg given 2 or 3 times per day. Increase dose gradually if needed. For extended-release tablets, begin with 0.5 mg once a day; gradually increase if needed and tolerated. 2. To switch therapy from immediaterelease to extended-release tablets, start with a once-daily dose of the extended-release product equal to the total daily dose of the immediate-release tablets. 3. Avoid abrupt discontinuation due to the possibility of withdrawal. When discontinuing therapy or decreasing the daily dose, reduce dosage gradually. It is recommended the daily dose be decreased by no more than 0.5 mg q 3 days; some clients may require an even slower dosage reduction. If significant withdrawal symptoms develop, reinstitute the previous dosing schedule and try a less rapid discontinuation schedule. 4. Store from 1530C (5986F) protected from moisture. ASSESSMENT 1. Note reasons for therapy, other agents trialed and outcome. 2. With anxiety, evaluate/compare before and after therapy initiated. 3. Monitor CBC, liver and renal function during prolonged therapy. CLIENT/FAMILY TEACHING 1. Do not chew, crush, or break the extended-release tablet. 2. Immediate-release and extended-release tablets are interchangeable on a daily mg-to-mg basis. Immediate-release tablets may be administered sublingually if difficulty swallowing tablets. 3. Mix Intensol oral solution with liquids or semi-solid foods such as water, juices, soda, or soda-like beverages, applesauce, and puddings. Use the calibrated dropper provided. Draw up the required amount, squeeze the dropper contents into the liquid or semi-solid food, and stir gently for a few seconds. Do not prepare and store doses for future use.

Bold Italic = life threatening side effect

= black box warning

W = Available in Canada