The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a history of alcohol or drug abuse. There is an increased risk of pharmacodependency with the combined use of several benzodiazepines regardless of the anxiolytic or hypnotic indication. Cases of abuse have also been reported.

Once dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms. These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion, irritability and insomnia.

In severe cases the following symptoms may occur: During discontinuation of alprazolam treatment, the dosage should be reduced slowly in keeping with good medical practice. Some patients may require even slower dosage reduction. Rebound insomnia and anxiety: It may be accompanied by other reactions including mood changes, mild dysphoria, anxiety or sleep disturbances, abdominal and muscle cramps, vomiting, sweating, tremor and restlessness. Duration of treatment It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased.

Moreover it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.

There are indications that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. When benzodiazepines with a long duration of action are being used it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.

In a controlled postmarketing discontinuation study of panic disorder patients, the duration of treatment 3 months compared to 6 months had no effect on the ability of patients to taper to zero dose. 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 3 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.

Status Epilepticus and its Treatment The medical event voluntary reporting system shows that withdrawal seizures have been reported in association with the discontinuation of XANAX.

In most cases, only a single seizure was reported; however, multiple seizures and status epilepticus were reported as well. 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. Risk of Dose Reduction 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. CNS Depression and Impaired Performance Because of its CNS depressant effects, patients receiving XANAX 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. Risk of Fetal Harm Benzodiazepines can potentially cause fetal harm when administered to pregnant women.

If XANAX 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, XANAX 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.

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.

The coadministration of alprazolam with these agents is not recommended. Drugs demonstrated to be CYP 3A inhibitors on the basis of clinical studies involving alprazolam caution and consideration of appropriate alprazolam dose reduction are recommended during coadministration with the following drugs Nefazodone Coadministration of nefazodone increased alprazolam concentration two-fold.

HIV protease inhibitors 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.

Panic disorder has been associated with primary and secondary major depressive disorders and increased reports of suicide among untreated patients.

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

Use in Patients with Concomitant Illness 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. What am I supposed to do? You are probably stuck like Chuck for the duration of the month.

You'll have to count it as a lesson learned. I live in a rural area, right at the state line, and on my side, there are only 2 pharmacies I can use. When I try to take my scripts across the state line, the pharmacists always say they're not familiar with my doctor!

But the one pharmacy is right next to my doctor's clinic, so it's real convenient, especially since they tend to schedule me in the afternoons. That doesn't give me time to make it to my other pharmacy I'd rather use, but they obviously have the better brands.

Before taking alprazolam, tell your doctor if you are allergic to any drugs, or if you have: If you have any of these conditions, you may need a dose adjustment or special tests to safely take alprazolam. FDA pregnancy category D. Alprazolam can cause birth defects in an unborn baby. Do not use alprazolam without your doctor's consent if you are pregnant.

Tell your doctor if you become pregnant during treatment. Use an effective form of birth control while you are using this medication. Alprazolam can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. The sedative effects of this medication may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines.

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