For treating panic disorders, the recommended alprazolam dosing is as follows: ● Starting dose : 0.5 mg three times a day. ● Titration : Dose may be increased at intervals of every three to four days, in increments not to exceed 1 mg per day. ● Maximum dose : Some patients in clinical trials required a daily dose as high as 10 mg, in divided doses. Patients requiring a daily dose above 4 mg should have their dose frequently reassessed. Post-marketing studies have shown patients taking a daily dose above 4 mg are able to taper to 50% of their dose without apparent loss of clinical effect (Pharmacia & Upjohn Company LLC, 2021). Adverse effects Common adverse effects caused by alprazolam include: ● Appetite changes, which can lead to weight loss or gain. ● Changes in libido (may increase or decrease). ● Dry mouth. ● Dysarthria. ● Fatigue. ● Hypotension. ● Impaired memory. ● Insomnia. ● Poor balance or coordination. (George & Tripp, 2021; Pharmacia & Upjohn Company LLC, 2021) Alprazolam has a short half-life, is rapidly absorbed, and has low lipophilicity. In addition, it’s known to cause euphoria and disinhibition. Due to these effects, alprazolam can be addictive. Misuse and abuse of alprazolam is possible, and the drug is a controlled substance with Schedule IV (C-IV) designation (George & Tripp, 2021) by the U.S. Drug Enforcement Administration (DEA). The drug has a boxed warning from the FDA regarding abuse, misuse, and addiction potential. Withdrawal If alprazolam is to be discontinued, the dose should be tapered. A suggested taper is to decrease the dose by no more than 0.5 mg every three days. Some patients will require a more gradual dose reduction. Alprazolam has a boxed warning regarding risks associated with rapid withdrawal, emphasizing the need for gradual tapering of the dose. Drug interactions Central nervous system (CNS) depressants ● Cognitive impairment. ● Difficulty concentrating. ● Drowsiness or dizziness. Using alprazolam with other CNS depressants can produce additive CNS depression. Co-administration should be avoided when possible. The dosage and duration of use for alprazolam should be limited if it must be used with other CNS Lorazepam (Ativan) Lorazepam is FDA-indicated for short-term treatment of anxiety symptoms or anxiety related to depressive disorders. The initial starting dose is 2-3 mg, which may be repeated two or three times per day. The maximum dose is 10 mg per day. Doses range from 1 to 10 mg per day (Ghiasi et al., 2022). Diazepam (Valium) Diazepam has FDA approval for managing anxiety disorders and short-term treatment of anxiety symptoms. It’s also prescribed anticonvulsants with GABAergic properties. Pregabalin is believed to act by reducing neurotransmitter release through activity at the alpha-2 delta subunit of calcium channels. The strongest evidence for pregabalin as an anxiolytic comes from randomized controlled trials showing similar efficacy as benzodiazepines for treating GAD (Garakani et al., 2020). It has also been shown to have some efficacy for treating SAD, but this Pregabalin and Gabapentin Pregabalin (Lyrica) and gabapentin (Neurontin) are
depressants (Pharmacia & Upjohn Company LLC, 2021). Example medications include: ● Alcohol.
● Anticonvulsants. ● Antihistamines. ● Psychotropic medications. CYP3A Inhibitors
Alprazolam is heavily metabolized by CYP3A4. Using strong CYP3A4 inhibitors together with alprazolam is contraindicated, as it results in increased alprazolam serum concentrations and increased risk for adverse reactions. Consider reducing the alprazolam dose if it must be used concomitantly with a moderate or weak CYP3A4 inhibitor. ● Example strong CYP3A4 inhibitors include clarithromycin, itraconazole, and ketoconazole. ● Example moderate or weak CYP3A4 inhibitors include erythromycin, fluvoxamine, and nefazodone. CYP3A Inducers YP3A4 inducers may decrease alprazolam plasma levels. Caution should be used if co-prescribing alprazolam with a CYP3A4 inducer cannot be avoided. An example CYP3A4 inducers include carbamazepine and phenytoin. ● Digoxin . Concomitant use of digoxin with alprazolam has resulted in increased digoxin plasma concentrations. This effect is particularly pronounced in patients aged 65 years and above. If alprazolam and digoxin must be used together, frequently monitor digoxin serum concentrations and assess the patient for digoxin toxicity. Consider reducing digoxin dose. ● Opioids . Concomitant use of opioids with benzodiazepines increases risk for respiratory depression. Benzodiazepines exert effect at the gamma-aminobutyric acid (GABA) sites, while opioids primarily bind mu receptors. Both sites are located within the CNS and play a key role in regulating respiration. If this combination cannot be avoided, the dosage and duration of use for both the opioid and benzodiazepine should be limited. Patients must be closely monitored for respiratory depression and sedation. Alprazolam has a boxed warning regarding risks associated with this interaction. In addition to monitoring cardiovascular and respiratory function, periodically order a complete blood count (CBC) and liver function tests (LFTs) in patients chronically treated with alprazolam. Alprazolam is a substance which can cause misuse, abuse, and dependence. Monitor patients for signs of misuse, abuse, drug diversion, and physical dependence. Exercise caution or avoid prescribing alprazolam in patients with a history of substance use disorder.
Lorazepam is often the anxiolytic of choice for inpatient settings, due to a rapid onset of action (1-3 minutes) when given intravenously (Ghiasi et al., 2022).
for relief of preoperative anxiety. The recommended anxiolytic dose is 2 to 10 mg and can be given two to four times daily.
use required high daily doses of 450 or 600 mg. It was approved for treating GAD by the European Union in 2006 but did not receive FDA approval for the same use in 2009. Pregabalin is generally well tolerated, with dizziness, sedation, and weight gain among the medication’s common adverse effects. It’s important to note that pregabalin is a Schedule V controlled substance per the U.S. Drug Enforcement Administration (DEA), due to the risk for dependence and abuse. Clinicians should
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Book Code: RPTTX2024
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