Because of its CNS depressant effects, patients receiving alprazolam extended-release tablets should be cautioned against engaging in hazardous occupations or activities requiring complete mental alertness such as operating machinery or driving a motor vehicle. Symptoms of overdose may include: Moderate The plasma concentrations of alprazolam may be elevated when administered concurrently with cobicistat. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines. Moderate CNS depressants, such as anxiolytics, sedatives, and hypnotics, can increase the sedative effects of trihexyphenidyl.
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Also tell your health care professional if you have any other types of allergies , such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully. Appropriate studies have not been performed on the relationship of age to the effects of alprazolam in the pediatric population. Safety and efficacy have not been established.
Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of alprazolam in the elderly. However, elderly patients are more likely to have unwanted effects eg, severe drowsiness, dizziness, confusion, clumsiness, or unsteadiness and kidney, liver, or lung problems, which may require caution and an adjustment in the dose for patients receiving this medicine.
Studies in women breastfeeding have demonstrated harmful infant effects. An alternative to this medication should be prescribed or you should stop breastfeeding while using this medicine. Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary.
When you are taking this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive. Using this medicine with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take.
Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines. Using this medicine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you.
Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Using this medicine with any of the following is usually not recommended, but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use this medicine, or give you special instructions about the use of food, alcohol, or tobacco.
The presence of other medical problems may affect the use of this medicine. Make sure you tell your doctor if you have any other medical problems, especially:. It is very important that your doctor check your progress at regular visits to make sure this medicine is working properly. Blood and urine tests may be needed to check for any unwanted effects. Using this medicine while you are pregnant can harm your unborn baby. Use an effective form of birth control to keep from getting pregnant.
If you think you have become pregnant while using the medicine, tell your doctor right away. Using any of them together with this medicine may increase the chance of serious side effects. This medicine will add to the effects of alcohol and other central nervous system CNS depressants. CNS depressants are medicines that slow down the nervous system, which may cause drowsiness or make you less alert. Some examples of CNS depressants are antihistamines or medicine for hay fever , allergies , or colds, sedatives , tranquilizers, or sleeping medicine, prescription pain medicine or narcotics, barbiturates or seizure medicines, muscle relaxants, or anesthetics numbing medicines , including some dental anesthetics.
This effect may last for a few days after you stop using this medicine. Check with your doctor before taking any of the above while you are using this medicine. If you develop any unusual and strange thoughts or behavior while you are taking alprazolam , be sure to discuss it with your doctor. Some changes that have occurred in people taking this medicine are like those seen in people who drink alcohol and then act in a manner that is not normal. Other changes may be more unusual and extreme, such as confusion, worsening of depression , hallucinations seeing, hearing, or feeling things that are not there , suicidal thoughts, and unusual excitement, nervousness, or irritability.
Alprazolam may cause some people, especially older persons, to become drowsy, dizzy, or less alert than they are normally. Make sure you know how you react to this medicine before you drive, use machines, or do anything else that could be dangerous if you are dizzy, or are not alert or able to see well. Do not stop taking this medicine without checking first with your doctor.
Your doctor may want you to gradually reduce the amount you are using before stopping it completely. This may help prevent a worsening of your condition and reduce the possibility of withdrawal symptoms, such as convulsions seizures , stomach or muscle cramps, sweating, tremors , vomiting, or unusual behavior. This medicine may be habit-forming. If you feel that the medicine is not working as well, do not use more than your prescribed dose. Call your doctor for instructions. Do not take other medicines unless they have been discussed with your doctor.
Find big savings at pharmacies near you with GoodRx discount coupons. Overview TOP Alprazolam is used to relieve symptoms of anxiety , including anxiety caused by depression. This medicine is available only with your doctor's prescription. Do not eat grapefruit or drink grapefruit juice while you are using this medicine. Dosing TOP The dose of this medicine will be different for different patients.
For oral dosage forms solution, tablets, or orally disintegrating tablets: Your doctor may increase your dose as needed. However, the dose is usually not more than 4 mg per day. Older adults—At first, 0. Children—Use and dose must be determined by your doctor. For oral dosage form extended-release tablets: However, the dose is usually not more than 10 mg per day. Keep out of the reach of children.
Do not keep outdated medicine or medicine no longer needed. Ask your healthcare professional how you should dispose of any medicine you do not use. Before Using TOP In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. Moderate Drugs that may inhibit CYP3A4, such as erythromycin, may inhibit the metabolism of alprazolam.
Use alprazolam and erythromycin with caution and consider alprazolam dose reduction. Moderate Concomitant administration of alprazolam with CNS-depressant drugs, including anticonvulsants, can potentiate the CNS effects e. Additionally, eslicarbazepine is an inducer of the hepatic CYP3A4 isoenzyme thereby having the potential to lower the plasma levels of medications metabolized through these pathways. The effectiveness of medications such as alprazolam could theoretically be decreased.
Moderate Concomitant administration of benzodiazepines with eszopiclone can potentiate the CNS effects e. The concurrent use of eszopiclone with other anxiolytics, sedatives, and hypnotics at bedtime or in the middle of the night is not recommended. In addition, the risk of next-day psychomotor impairment is increased during co-administration of eszopiclone and other CNS depressants, which may decrease the ability to perform tasks requiring full mental alertness such as driving.
If used together, a reduction in the dose of one or both drugs may be needed. Major Alcohol is associated with CNS depression. The combined use of alcohol and CNS depressants can lead to additive CNS depression, which could be dangerous in tasks requiring mental alertness and fatal in overdose. Alcohol taken with other CNS depressants can lead to additive respiratory depression, hypotension, profound sedation, or coma.
Consider the patient's use of alcohol or illicit drugs when prescribing CNS depressant medications. In many cases, the patient should receive a lower dose of the CNS depressant initially if the patient is not likely to be compliant with avoiding alcohol. Ethinyl Estradiol; Ethynodiol Diacetate: Ethinyl Estradiol; Norethindrone Acetate: Ethinyl Estradiol; Norethindrone Acetate; Ferrous fumarate: Ethinyl Estradiol; Norethindrone; Ferrous fumarate: Moderate Drugs that inhibit the CYP3A metabolic pathway, such as fluconazole, may profoundly decrease alprazolam clearance.
Because binding at the receptor is competitive and flumazenil has a much shorter duration of action than do most benzodiazepines, it is possible for the effects of flumazenil to dissipate sooner than the effects of the benzodiazepine. Flumazenil does not affect the pharmacokinetics of the benzodiazepines. Abrupt awakening can cause dysphoria, agitation, and possibly increased adverse effects. If administered to patients who have received a benzodiazepine chronically, abrupt interruption of benzodiazepine agonism by flumazenil can induce benzodiazepine withdrawal including seizures.
Flumazenil has minimal effects on benzodiazepine-induced respiratory depression; suitable ventilatory support should be available, especially in treating acute benzodiazepine overdose. Flumazenil does not reverse the actions of barbiturates, opiate agonists, or tricyclic antidepressants. Moderate Clinical study results suggest that the interaction between alprazolam, a CYP3A4 substrate fluoxetine, a CYP3A4 inhibitor may be of clinical significance, and caution is recommended during co-administration.
Monitor patients closely for excessive alprazolam-related side effects. Drugs that can cause CNS depression, if used concomitantly with olanzapine, can increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, dizziness, and orthostatic hypotension. Besides ethanol, clinicians should use other anxiolytics, sedatives, and hypnotics cautiously with olanzapine.
A reduction in alprazolam dose may be needed in some patients. Major Coadministration of marijuana with benzodiazepines may result in an exaggerated sedative effect. Instruct patients receiving these medications concurrently not to drive or operate machinery. Major Coadministration of alprazolam and fosamprenavir is not recommended. Fosamprenavir is a potent CYP3A4 inhibitor. Major Grapefruit juice has been shown to significantly increase peak serum concentrations and AUC of triazolam and oral midazolam.
According to the manufacturer, a similar interaction may theoretically occur with alprazolam; however, one in-vivo pharmacokinetic study demonstrated that the bioavailability of alprazolam is unlikely to be effected by coadministration with grapefruit juice. Minor Patients taking benzodiazepines for insomnia should not use caffeine-containing products, such as green tea, prior to going to bed as these products may antagonize the sedative effects of the benzodiazepine. Moderate Guanabenz is associated with sedative effects.
Guanabenz can potentiate the effects of CNS depressants such as benzodiazepines, when administered concomitantly. Moderate Guanfacine has been associated with sedative effects and can potentiate the actions of other CNS depressants including benzodiazepines. Minor Caffeine, an active constituent of guarana, is a CNS stimulant associated with heightened attentiveness and insomnia, and is used to treat or prevent drowsiness or fatigue; patients taking benzodiazepines for insomnia should not use guarana-containing products prior to going to bed as these products may antagonize the sedative effects of the benzodiazepine or zolpidem.
Moderate Mild to moderate increases in haloperidol plasma concentrations have been reported during concurrent use of haloperidol and CYP3A4 substrates such as alprazolam. Until more data are available, it is advisable to closely monitor for adverse events when alprazolam is coadministered with haloperidol. Concomitant administration of alprazolam with CNS-depressant drugs including antipsychotics can potentiate the CNS effects e. Moderate Hydantoin anticonvulsants can theoretically add to the CNS-depressant effects of other CNS depressants including the benzodiazepines.
In addition, potential hepatic enzyme inducers such as hydantoins can theoretically increase the clearance of benzodiazepines metabolized by oxidative metabolism, leading to lower benzodiazepine concentrations. Moderate Methyldopa is associated with sedative effects. Methyldopa can potentiate the effects of CNS depressants such as barbiturates, benzodiazepines, opiate agonists, or phenothiazines when administered concomitantly.
Hydrocodone; Potassium Guaiacolsulfonate; Pseudoephedrine: Major Coadministration of alprazolam and idelalisib is not recommended. Idealalisib is a potent CYP3A4 inhibitor. Moderate Drugs that can cause CNS depression, if used concomitantly with iloperidone, may increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, and dizziness. Caution should be used when iloperidone is given in combination with other centrally-acting medications including anxiolytics, sedatives, and hypnotics.
Severe Coadministration of indinavir with alprazolam is contraindicated. Indinavir is expected to significantly inhibit the CYP3A4 metabolism of alprazolam, producing large increases in the plasma concentrations which may lead to excessive sedation and potentially respiratory depression. Consider an alternative benzodiazepine that does not undergo oxidative metabolism, such as lorazepam, oxazepam, or temazepam.
Moderate Concomitant use of isavuconazonium with alprazolam may result in increased serum concentrations of alprazolam. Alprazolam is primarily metabolized by the hepatic isoenzyme CYP3A4; isavuconazole, the active moiety of isavuconazonium, is a moderate inhibitor of this enzyme. Caution and close monitoring are advised if these drugs are used together.
Moderate Isoniazid can decrease the hepatic oxidative metabolism of benzodiazepines if administered concomitantly. Patients receiving alprazolam therapy should be monitored for signs of altered benzodiazepine response when alprazolam is initiated or discontinued. Moderate Rifampin is a potent inducer of the cytochrome P hepatic enzyme system. Rifampin could induce the CYP3A4-mediated metabolism of oxidized benzodiazepines, such as alprazolam.
Severe Coadministration of itraconazole and alprazolam is contraindicated. Itraconazole significantly impairs the CYP3A4 metabolism of alprazolam, resulting in elevated alprazolam concentrations, which may cause prolonged sedation and respiratory depression. When a single dose of alprazolam was administered to healthy patients receiving itraconazole, the mean AUC and half-live of alprazolam were increased 2.
Lorazepam, oxazepam, or temazepam may be safer alternatives if a benzodiazepine must be administered in combination with itraconazole, as these benzodiazepines are not oxidatively metabolized. Moderate Use caution when administering ivacaftor and alprazolam concurrently because patients are at increased risk for adverse effects from alprazolam. Co-administration of ivacaftor with midazolam, another CYP3A substrate, increased midazolam exposure by 1.
Kava Kava, Piper methysticum: Major The German Commission E warns that any substances that act on the CNS, including psychotropic agents, may interact with kava kava. While the interactions can be pharmacodynamic in nature, kava kava has been reported to inhibit many CYP isozymes i. Patients on benzodiazepine therapy should avoid concomitant administration of kava kava. Patients should discuss the use of herbal supplements with their health care professional prior to consuming kava kava and should not abruptly stop taking their prescribed medications.
Severe Coadministration of ketoconazole and alprazolam is contraindicated. Ketoconazole significantly impairs the CYP3A4 metabolism of alprazolam, resulting in elevated alprazolam concentrations. Lorazepam, oxazepam, or temazepam may be safer alternatives if a benzodiazepine must be administered in combination with ketoconazole, as these benzodiazepines are not oxidatively metabolized. Moderate A clinically relevant increase in the plasma concentration of alprazolam may occur if given with letermovir.
Coadministration is not recommended if the patient is also receiving cyclosporine, because the magnitude of the interaction may be increased. If coadministration of all 3 drugs cannot be avoided, a dosage reduction of alprazolam should be considered. Alprazolam is primarily metabolized by CYP3A4. Concurrent administration with other moderate to strong inhibitors increased alprazolam exposure by 1.
Moderate Concomitant administration of benzodiazepines with CNS-depressant drugs, including opiate agonists, can potentiate the CNS effects of either agent. Moderate Concurrent use of many CNS active drugs, including benzodiazepines, with levomilnacipran has not been evaluated by the manufacturer. Therefore, caution is advisable when combining anxiolytics, sedatives, and hypnotics or other psychoactive medications with levomilnacipran.
Moderate Because lithium has the potential to impair cognitive and motor skills, caution is advisable during concurrent use of other medications with centrally-acting effects including anxiolytics, sedatives, and hypnotics. Major Concomitant use of lomitapide and alprazolam may significantly increase the serum concentration of lomitapide. Major Coadministration of alprazolam and lopinavir; ritonavir is not recommended. Minor Although loratadine is considered a 'non-sedating' antihistamine, dose-related sedation has been noted.
For this reason, it would be prudent to monitor for drowsiness when used concurrently with other CNS depressants like benzodiazepines. Moderate Concomitant administration of alprazolam with CNS-depressant drugs, including antipsychotics, can potentiate the CNS effects of either agent. Moderate Lumacaftor; ivacaftor may decrease the systemic exposure and therapeutic efficacy of alprazolam. If used together, alprazolam dosages may need to be adjusted.
Alprazolam is a CYP3A substrate. Lumacaftor is a strong CYP3A inducer. Moderate Due to the CNS effects of lurasidone, caution should be used when lurasidone is given in combination with other centrally acting medications such as anxiolytics, sedatives, and hypnotics, including benzodiazepines. Minor Because of the CNS-depressant effects of magnesium sulfate, additive central-depressant effects can occur following concurrent administration with CNS depressants such as benzodiazepines.
Caution should be exercised when using these agents concurrently. Moderate Benzodiazepines or other CNS depressants should be combined cautiously with maprotiline because they could cause additive depressant effects and possible respiratory depression or hypotension. The combination of benzodiazepines and maprotiline is commonly used clinically and is considered to be safe as long as patients are monitored for excessive adverse effects from either agent.
Maprotiline may lower the seizure threshold, so when benzodiazepines are used for anticonvulsant effects the patient should be monitored for desired clinical outcomes. Major Use caution when combining melatonin with the benzodiazepines; when the benzodiazepine is used for sleep, co-use of melatonin should be avoided. In animal studies, melatonin has been shown to increase benzodiazepine binding to receptor sites. In one case report, a benzodiazepine-dependent woman with an 11 year history of insomnia weaned and discontinued her benzodiazepine prescription within a few days without rebound insomnia or apparent benzodiazepine withdrawal when melatonin was given.
In another case report, the ingestion of excessive melatonin along with normal doses of chlordiazepoxide and an antidepressant resulted in lethargy and short-term amnestic responses. Both cases suggest additive pharmacodynamic effects. In a clinical trial, there was clear evidence for a transitory pharmacodynamic interaction between melatonin and another hypnotic agent one hour following co-dosing. Concomitant administration resulted in increased impairment of attention, memory and coordination compared to the hypnotic agent alone.
Use of more than one agent for hypnotic purposes may increase the risk for over-sedation, CNS effects, or sleep-related behaviors. Be alert for unusual changes in moods or behaviors. Patients reporting unusual sleep-related behaviors likely should discontinue melatonin use. Moderate Concomitant administration of benzodiazepines with meprobamate can potentiate the CNS effects e. Major Concurrent use of opiate agonists with benzodiazepines may cause respiratory depression, hypotension, profound sedation, and death.
If concurrent use is necessary, use the lowest effective dose and minimum duration possible. If methadone is initiated for pain in an opioid-naive patient taking a benzodiazepine, use an initial methadone dose of 2. If a benzodiazepine is prescribed for an indication other than epilepsy in a patient taking an opiate agonist, use a lower initial benzodiazepine dose and titrate to response. In patients treated with methadone for opioid use disorder, cessation of benzodiazepines or other CNS depressants is preferred in most cases.
Consider alternatives to benzodiazepines for conditions such as anxiety or insomnia during methadone maintenance treatment. Moderate Concurrent use of benzodiazepines and other CNS active medications including skeletal muscle relaxants, can potentiate the CNS effects of either agent. Moderate CNS depression can be increased when methscopolamine is combined with other CNS depressants such as any anxiolytics, sedatives, and hypnotics. Minor Combined use of metoclopramide and other CNS depressants, such as anxiolytics, sedatives, and hypnotics, can increase possible sedation.
Other drugs that may also cause drowsiness, such as benzodiazepines, should be used with caution. Moderate The concomitant administration of metyrosine with benzodiazepines can result in additive sedative effects. Coadministration of mifepristone may lead to an increase in serum levels of drugs that are CYP3A4 substrates, such as alprazolam. Due to the slow elimination of mifepristone from the body, such interactions may be observed for a prolonged period after mifepristone administration.
Moderate Concurrent use of many CNS-active drugs with milnacipran or levomilnacipran has not been evaluated by the manufacturer. Therefore, caution is advisable when combining anxiolytics, sedatives, and hypnotics or other psychoactive medications with these medications. Minor Injectable minocycline contains magnesium sulfate heptahydrate.
Because of the CNS-depressant effects of magnesium sulfate, additive central-depressant effects can occur following concurrent administration with CNS depressants such as benzodiazepines. Moderate Consistent with the pharmacology of mirtazapine and the drug's side effect profile, additive effects may occur with other CNS-active agents, including benzodiazepines.
Moderate Avoid the concomitant use of mitotane with alprazolam; if coadministration cannot be avoided, monitor for decreased efficacy of alprazolam. Mitotane is a strong CYP3A4 inducer and alprazolam is a CYP3A4 substrate; coadministration may result in decreased plasma concentrations of alprazolam. Additionally, mitotane can cause sedation, lethargy, vertigo, and other CNS adverse reactions; additive CNS effects may occur initially when mitotane is given concurrently with alprazolam.
MAOIs can cause a variable change in seizure patterns, so careful monitoring of the patient with epilepsy is required when benzodiazepines are used in the treatment of epilepsy. If morphine is initiated in a patient taking a benzodiazepine, reduce initial dosages and titrate to clinical response. For extended-release tablets, start with morphine 15 mg PO every 12 hours, and for extended-release capsules, start with 30 mg PO every 24 hours or less.
Moderate Concomitant use of nabilone with other CNS depressants can potentiate the effects of nabilone on respiratory depression. Major In general, nefazodone is not recommended for use with alprazolam in most patients. Nefazodone inhibits the hepatic CYP3A4 isoenzyme and substantially increases the plasma concentrations of alprazolam. Alprazolam AUC and half-life are increased 2-fold by the addition of nefazodone.
Major Coadministration of alprazolam and nelfinavir is not recommended. Nelfinavir is a potent CYP3A4 inhibitor. Major Netupitant is a moderate inhibitor of CYP3A4 and should be used with caution in patients receiving concomitant medications that are primarily metabolized through CYP3A4, such as alprazolam. The plasma concentrations of CYP3A4 substrates can increase when co-administered with netupitant.
The inhibitory effect on CYP3A4 can last for multiple days. When midazolam, another benzodiazepine metabolized via CYP3A4, was administered with netupitant, the systemic exposure to midazolam was significantly increased. Increased benzodiazepine exposure may lead to increased sedation or respiratory depression. Monitor patients closely who receive concurrent therapy. Moderate Nevirapine may induce the metabolism of certain benzodiazepines that are metabolized through the cytochrome P system including alprazolam.
Patients should be monitored closely for loss of clinical effects. Co-administration with nicardipine may lead to an increase in serum levels of drugs that are CYP3A4 substrates including alprazolam. Niifedipine may theoretically inhibit CYP3A4 metabolism of alprazolam. Coadminister these drugs with caution. Increased alprazolam serum concentrations may occur, leading to an increased risk of alprazolam-related adverse reactions.
Monitor patients carefully, as the alprazolam dosage may need to be decreased. Minor Nitroglycerin can cause hypotension. This action may be additive with other agents that can cause hypotension such as benzodiazepines. Patients should be monitored more closely for hypotension if nitroglycerin is used concurrently with benzodiazepines.
Moderate Obeticholic acid may increase the exposure to concomitant drugs that are CYP1A2 substrates, such as alprazolam. Therapeutic monitoring is recommended with coadministration. Plasma concentrations and efficacy of alprazolam may be reduced if these drugs are administered concurrently. In addition, concomitant administration of alprazolam with CNS-depressant drugs, including anticonvulsants, can potentiate the CNS effects e. Moderate Additive CNS depression may occur when oxybutynin is used concomitantly with other CNS-depressant drugs, including anxiolytics, sedatives, and hypnotics.
If the extended-release oxymorphone tablets are used concurrently with a CNS depressant, use an initial dosage of 5 mg PO every 12 hours. Moderate Drugs that can cause CNS depression, if used concomitantly with paliperidone, can increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, and dizziness. Caution should be used when paliperidone is given in combination with other centrally-acting medications including anxiolytics, sedatives, and hypnotics, buprenorphine, butorphanol, dronabinol, THC, ethanol, nabilone, nalbuphine, opiate agonists, and pentazocine.
Moderate Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation. Minor The manufacturer of alprazolam states that in vitro studies suggest paroxetine may inhibit the metabolism of alprazolam via inhibition of CYP3A4. However, paroxetine is typically considered a major inhibitor of CYP2D6, for which alprazolam is not a substrate.
The potential for clinical interaction is uncertain. Be alert for any change in psychomotor performance or other benzodiazepine-related side effects when paroxetine is combined with alprazolam. Coadministration of pazopanib and alprazolam, a CYP3A4 substrate, may cause an increase in systemic concentrations of alprazolam. Use caution when administering these drugs concomitantly.
Moderate Patients taking benzodiazepines with perampanel may experience increased CNS depression. Monitor patients for adverse effects; dose adjustment of either drug may be necessary. Moderate Phenothiazines are CNS depressant drugs that may have cumulative effects when administered concurrently and they should be used cautiously with anxiolytic, sedative, and hypnotic type drugs, such as the benzodiazepines. Caution should be exercised during simultaneous use of these agents due to potential excessive CNS effects or additive hypotension.
Additionally, sleep-related behaviors, such as sleep-driving, are more likely to occur during concurrent use of other CNS depressants than with sedatives alone. Monitor for additive effects, unusual moods or behaviors, and warn about the potential effects to driving and other activities. The CNS depressant effects of topiramate can be potentiated pharmacodynamically by concurrent use of CNS depressant agents such as the benzodiazepines.
Concurrent use of topiramate and benzodiazepines associated with thrombocytopenia e. Moderate Due to the effects of pimozide on cognition, it should be used cautiously with other CNS depressants including benzodiazepines. Major Coadministration of posaconazole and alprazolam is not recommended. Posaconazole is a potent inhibitor of CYP3A4. Drugs that inhibit this metabolic pathway may profoundly decrease alprazolam clearance. While more study is needed, benzodiazepine-induced CNS sedation and other adverse effects might be increased in some individuals if DHEA is co-administered.
Moderate Pregabalin can potentiate the CNS-depressant action of other drugs such as benzodiazepines. Moderate Probenecid may inhibit the metabolism of the benzodiazepines, including those which are metabolized by conjugation e. In addition, pretreatment with probenecid shortened the induction time 85 vs. Patients receiving alprazolam therapy should be monitored for signs of altered benzodiazepine response when probenecid is initiated or discontinued.
Minor CNS depressants benzodiazepines can potentiate the CNS depression caused by procarbazine therapy, so these drugs should be used together cautiously. Moderate Somnolence is a commonly reported adverse effect of quetiapine; coadministration of quetiapine with anxiolytics, sedatives, and hypnotics, or other CNS depressants may result in additive sedative effects. Moderate Ramelteon is a sleep-promoting agent; therefore, additive pharmacodynamic effects are possible when combining ramelteon with benzodiazepines or other miscellaneous anxiolytics, sedatives, and hypnotics.
Pharmacokinetic interactions have been observed with the use of zolpidem. Ramelteon use with hypnotics of any kind is considered duplicative therapy and these drugs are generally not co-administered. Ranolazine may theoretically inhibit CYP3A4 metabolism of alprazolam. Moderate The CNS-depressant effects of MAOIs can be potentiated with concomitant administration of other drugs known to cause CNS depression including buprenorphine, butorphanol, dronabinol, THC, nabilone, nalbuphine, and anxiolytics, sedatives, and hypnotics.
Use these drugs cautiously with MAOIs; warn patients to not drive or perform other hazardous activities until they know how a particular drug combination affects them. In some cases, the dosages of the CNS depressants may need to be reduced. Moderate Use caution if coadministration of ribociclib with alprazolam is necessary, as the systemic exposure of alprazolam may be increased resulting in an increase in alprazolam-related adverse reactions; adjust the dose of alprazolam if necessary.
Moderate Rifabutin could induce the CYP3A4-mediated metabolism of oxidized benzodiazepines, such as alprazolam. Moderate Rifapentine could induce the CYP3A4-mediated metabolism of oxidized benzodiazepines, such as alprazolam. Moderate Due to the primary CNS effects of risperidone, caution should be used when risperidone is given in combination with other centrally acting medications including anxiolytics, sedatives, and hypnotics. Moderate Concomitant use of ropinirole with other CNS depressants, such as alprazolam, can potentiate the sedation effects of ropinirole.
Major Concomitant use of rotigotine with other CNS depressants, such as benzodiazepines, can potentiate the sedative effects of rotigotine. In theory, decreased exposure of drugs that are extensively metabolized by CYP3A4, such as alprazolam, may occur during concurrent use with rufinamide. Moderate Dopaminergic medications, including safinamide, may cause a sudden onset of somnolence which sometimes has resulted in motor vehicle accidents. Patients may not perceive warning signs, such as excessive drowsiness, or they may report feeling alert immediately prior to the event.
Because of possible additive effects, advise patients about the potential for increased somnolence during concurrent use of safinamide with other sedating medications, such as benzodiazepines. Major Coadministration of alprazolam and saquinavir boosted with ritonavir is not recommended. Saquinavir boosted with ritonavir is a potent CYP3A4 inhibitor.
Minor The manufacturer of alprazolam states that in vitro studies suggest sertraline may inhibit the metabolism of alprazolam via inhibition of CYP3A4. Be alert for any change in psychomotor performance or other benzodiazepine-related side effects when sertraline is combined with alprazolam. Monitor patients for adverse effects of alprazolam, such as sedation. Moderate Sincalide-induced gallbladder ejection fraction may be affected by benzodiazepines.
False study results are possible in patients with drug-induced hyper- or hypo-responsiveness; thorough patient history is important in the interpretation of procedure results. Moderate Concomitant use of skeletal muscle relaxants with benzodiazepines can result in additive CNS depression. Severe Sodium oxybate should not be used in combination with CNS depressant anxiolytics, sedatives, and hypnotics or other sedative CNS depressant drugs. Specifically, sodium oxybate use is contraindicated in patients being treated with sedative hypnotic drugs.
Sodium oxybate GHB has the potential to impair cognitive and motor skills. For example, the concomitant use of barbiturates and benzodiazepines increases sleep duration and may contribute to rapid onset, pronounced CNS depression, respiratory depression, or coma when combined with sodium oxybate. John's Wort, Hypericum perforatum: John's Wort may induce the hepatic CYP3A4 metabolism of alprazolam which is metabolized by oxidation.
It would be prudent to avoid coadministration of St. John's Wort with alprazolam. Benzodiazepines that are not metabolized by CYP3A4 such as oxazepam or lorazepam may be alternatives if a benzodiazepine is required in combination with St. Moderate CNS depressant drugs may have cumulative effects when administered concurrently and they should be used cautiously with suvorexant. A reduction in dose of the CNS depressant may be needed in some cases. These agents include the benzodiazepines.
If tapentadol is initiated in a patient taking a benzodiazepine, a reduced initial dosage of tapentadol is recommended. If the extended-release tapentadol tablets are used concurrently with a benzodiazepine, use an initial tapentadol dose of 50 mg PO every 12 hours. Moderate Teduglutide may increase absorption of benzodiazepines or other psychotropic agents because of it's pharmacodynamic effect of improving intestinal absorption.
In studies with teduglutide, one of the subjects was receiving concomitant treatment with prazepam and experienced dramatic deterioration in mental status progressing to coma during her first week of teduglutide therapy. Both drugs were discontinued, and the coma resolved 5 days later. Careful monitoring and possible dose adjustment of the psychotropic agent is recommended.
Moderate Close clinical monitoring is advised when administering alprazolam with telaprevir due to an increased potential for serious alprazolam-related adverse events. If alprazolam dose adjustments are made, re-adjust the dose upon completion of telaprevir treatment. Predictions about the interaction can be made based on the metabolic pathway of alprazolam. Alprazolam is metabolized by the hepatic isoenzyme CYP3A4; telaprevir inhibits this isoenzyme.
Coadministration may result in elevated alprazolam plasma concentrations. Major Coadministration of alprazolam and telithromycin is not recommended. Telithromycin is a potent CYP3A4 inhibitor. Moderate Use caution if coadministration of telotristat ethyl and alprazolam is necessary, as the systemic exposure of alprazolam may be decreased resulting in reduced efficacy. If these drugs are used together, monitor patients for suboptimal efficacy of alprazolam; consider increasing the dose of alprazolam if necessary.
Moderate Concurrent use of tetrabenazine and drugs that can cause CNS depression, such as benzodiazepines, can increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, dizziness, and orthostatic hypotension. Major The use of benzodiazepine anxiolytics, sedatives, or hypnotics with thalidomide may cause an additive sedative effect and should be avoided.
Thalidomide frequently causes drowsiness and somnolence. Dose reductions may be required. Patients should be instructed to avoid situations where drowsiness may be a problem and not to take other medications that may cause drowsiness without adequate medical advice. Moderate Aminophylline has been reported to counteract the pharmacodynamic effects of diazepam. A proposed mechanism is competitive binding of aminophylline to adenosine receptors in the brain.
Whether a similar interaction occurs with other benzodiazepines is not known. If aminophylline therapy is initiated or discontinued, monitor the clinical response to benzodiazepines. Moderate Theophylline has been reported to counteract the pharmacodynamic effects of diazepam. A proposed mechanism is competitive binding of theophylline to adenosine receptors in the brain. If theophylline therapy is initiated or discontinued, monitor the clinical response to benzodiazepines.
Moderate Thiothixene can potentiate the CNS-depressant action of other drugs such as benzodiazepines. Moderate Because of the possible additive effects of drugs that depress the central nervous system, benzodiazepines should be used with caution in patients receiving tiagabine. Major Coadministration of alprazolam and tipranavir is not recommended. Tipranavir is a potent CYP3A4 inhibitor.
Moderate The clinical significance of the pharmacokinetic effect of tobacco smoking on alprazolam clearance is unclear. No significant differences between groups were found in the Cmax or AUC. Because alprazolam is a primary substrate of CYP3A4, further evaluation of this potential interaction is needed in order to determine its clinical impact to patients. Moderate Consider a reduced dose of alprazolam is concurrent use of verapamil is necessary.
Moderate CNS depressants should be used cautiously in patients receiving trazodone because of additive CNS-depressant effects, including possible respiratory depression or hypotension. A dose reduction of one or both drugs may be warranted. Moderate Concomitant administration of benzodiazepines with CNS-depressant drugs, such as tricyclic antidepressants, can potentiate the CNS effects of either agent.
Tricyclic antidepressants may also lower the seizure threshold leading to pharmacodynamic interactions with anticonvulsant benzodiazepines i. The significance of this interaction has not been described; therefore, patients should be monitored closely for symptoms of tricyclic toxicity during coadministration of these agents with alprazolam.
Moderate CNS depressants, such as anxiolytics, sedatives, and hypnotics, can increase the sedative effects of trihexyphenidyl. Moderate The concurrent use of trimethobenzamide with other medications that cause CNS depression, like the benzodiazepines, may potentiate the effects of either trimethobenzamide or the benzodiazepine. Major Any substances that act on the CNS, including psychoactive drugs and drugs used as anesthetic adjuvants e.
The valerian derivative, dihydrovaltrate, binds at barbiturate binding sites; valerenic acid has been shown to inhibit enzyme-induced breakdown of GABA in the brain; the non-volatile monoterpenes valepotriates have sedative activity. These interactions are probably pharmacodynamic in nature. There is a possibility of interaction with valerian at normal prescription dosages of anxiolytics, sedatives, and hypnotics including barbiturates and benzodiazepines.
Patients taking medications such as tricyclic antidepressants, lithium, MAOIs, skeletal muscle relaxants, SSRIs and serotonin norepinephrine reuptake inhibitors e. Patients should not abruptly stop taking their prescribed psychoactive medications. Valproic Acid, Divalproex Sodium: Moderate Vigabatrin may cause somnolence and fatigue. Drugs that can cause CNS depression, if used concomitantly with vigabatrin, may increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, and dizziness.
Caution should be used when vigabatrin is given in combination with benzodiazepines. Moderate Due to the CNS effects of vilazodone, caution should be used when vilazodone is given in combination with other centrally acting medications such as the benzodiazepines. Severe Coadministration of voriconazole and alprazolam is contraindicated.
Voriconazole is a strong CYP3A4 inhibitor and significantly impairs the CYP3A4 metabolism of alprazolam, resulting in elevated alprazolam concentrations. Lorazepam, oxazepam, or temazepam may be safer alternatives if a benzodiazepine must be administered in combination with voriconazole, as these benzodiazepines are not oxidatively metabolized. Moderate In premarketing studies, zaleplon potentiated the CNS effects of ethanol, imipramine, and thioridazine for at least 2 to 4 hours.
Other drugs that may have additive CNS effects with zaleplon but have not been studied include benzodiazepines. Moderate Zileuton may inhbit the CYP3A isoenzymes and reduce the metabolism of alprazolam, potentially increasing the risk for benzodiazepine toxicity. Moderate Ziprasidone has the potential to impair cognitive and motor skills. Moderate Concomitant administration of benzodiazepines with zolpidem can potentiate the CNS effects e.
For Intermezzo brand of sublingual zolpidem tablets, reduce the dose to 1. Concurrent use of zolpidem with other sedative-hypnotics, including other zolpidem products, at bedtime or the middle of the night is not recommended. In addition, sleep-related behaviors, such as sleep-driving, are more likely to occur during concurrent use of zolpidem and other CNS depressants than with zolpidem alone. Benzodiazepines act at the level of the limbic, thalamic, and hypothalamic regions of the CNS and can produce any level of CNS depression required including sedation, hypnosis, skeletal muscle relaxation, and anticonvulsant activity.
Recent evidence indicates that benzodiazepines exert their effects through enhancement of the gamma-aminobutyric acid GABA -benzodiazepine receptor complex. Activation of the BNZ-1 receptor is thought to mediate sleep while the BNZ-2 receptor affects muscle relaxation, anticonvulsant activity, motor coordination, and memory. Binding of GABA to the site opens the chloride channel resulting in a hyperpolarized cell membrane that prevents further excitation of the cell.
Benzodiazepines alleviate insomnia by decreasing the latency to sleep and increasing sleep continuity and total sleep time through their effects on GABA. Preliminary evidence suggests that alprazolam decreases cerebral blood flow and plasma epinephrine concentrations.