Alprazolam (Xanax) Indications and Dosage
- anxiety
- insomnia †
- panic disorder
- premenstrual dysphoric disorder (PMDD) †
- premenstrual syndrome (PMS) †
† non-FDA-approved indication
Alprazolam Indications / Dosage
For the treatment of anxiety disorders (i.e. generalized anxiety disorder), or transient symptoms of anxiety:
NOTE: For all dosage forms, dose increases should occur at intervals of 3 - 4 days. To discontinue alprazolam, decrease the daily dose by no more than 0.5 mg every 3 days; some patients may require slower dose reduction.
Oral dosage (immediate-release tablets, orally disintegrating tablets or oral solution):
Adults: 0.25 - 0.5 mg PO three times per day up to a maximum of 4 mg/day.
Elderly patients: 0.125 - 0.25 mg PO twice daily or three times per day. Federal OBRA guidelines recommend that the dose not exceed 0.75 mg/day PO in residents of skilled nursing facilities unless higher doses are necessary for functional status.
Adolescents and children 7 - 18 years: Definitive dosage recommendations have not been established. However, in one study of children 7 - 16 years old (n=13), initial doses of 0.005 mg/kg PO or 0.125 mg PO per dose were given three times per day for situational anxiety. Doses were increased in 0.125 - 0.25 mg increments to a maximum of 0.02 mg/kg PO per dose or 0.06 mg/kg/day PO. In another study of children with overanxious or avoidant disorder (n=30), initial doses were 0.25 mg PO per day for children <= 40 kg and 0.5 mg PO per day for those > 40 kg. Doses were titrated at 2-day intervals to a maximum of 0.04 mg/kg/day. Required doses ranged from 0.5 - 3.5 mg/day with a mean dose of 1.6 mg/day.
For the treatment of symptoms associated with panic disorder with or without agoraphobia:
NOTE: For all dosage forms, dose increases should occur at intervals of 3 - 4 days. To discontinue alprazolam, decrease the daily dose by no more than 0.5 mg every 3 days; some patients may require slower dose reduction.
Oral dosage (immediate-release tablets, orally disintegrating tablets or oral solution):
Adults: 0.5 mg PO three times per day; increase in 1 mg increments as needed, at intervals of 3 - 4 days. Dosages range from 1 to 10 mg/day; 4 mg/day is typically necessary.
Elderly patients: 0.125 - 0.25 mg PO twice daily or three times per day. Federal OBRA guidelines for skilled facilities recommend that the dose not exceed 2 mg/day PO unless higher dosages needed to maintain functional status.
Adolescents and children: Dosage not established.
Oral dosage (extended-release tablets, Xanax® XR):
NOTE: If patient is currently using immediate-release alprazolam (Xanax® ) 3 or 4 times a day, they may be switched to extended-release alprazolam (Xanax® XR) by calculating the total daily dose and administering once daily using the XR formulation.
Adults: Initially, 0.5 - 1 mg PO once a day; preferably in the morning. Increase in increments of <= 1 mg/day, at intervals of every 3 - 4 days. Dosages range from 1 to 10 mg/day; 3 - 6 mg/day is typically necessary. Up to 10 mg/day has been required in occasional patients.
Elderly patients: Initially, 0.5 mg PO once daily, preferably in the morning. Gradually increase as needed and tolerated; the elderly may be more sensitive to the effects of benzodiazepines. In younger patients, doses were increased in increments of <= 1 mg/day, at intervals of every 3 - 4 days. In general, Federal OBRA guidelines for skilled facilities recommend that the dose of alprazolam (immediate-release formulation) not exceed 2 mg/day PO unless higher dosages needed to maintain functional status.
Adolescents and children: Safe and effective use has not been established.
For the treatment of anxiety and mood-symptoms associated with premenstrual syndrome (PMS) † or premenstrual dysphoric disorder (PMDD) † that are unresponsive to non-pharmacologic therapy:
Oral dosage (immediate-release tablets or oral solution):
Adults: 0.25 mg PO three times daily administered during the luteal phase through the second day of menses has been studied and was found to be superior to placebo in treating the emotional symptoms associated with PMS. A maximum dose up to 4 mg/day is recommended. Dose should be tapered by 25% per day through menses. In a placebo-controlled, comparative study with oral progesterone of 138 subjects, after 3 months, alprazolam was superior to progesterone or placebo overall but progesterone was better than alprazolam for physical symptoms while alprazolam was better than progesterone for controlling mood and mental function. Alprazolam was initially dosed at 0.25 mg PO four times per day administered from day 18 of the menstrual cycle to the first day of menses with a taper on the first 2 menstrual days, however, dosing was flexible; patients could receive up to twelve 0.25 mg capsules/day if necessary. The actual alprazolam dose taken during the third treatment cycle was 1.5 mg/day PO.
For the short-term treatment of insomnia † :
NOTE: Alprazolam is not usually recommended for hypnotic use.
Oral dosage:
Adults: Initially, 0.25 - 0.5 mg PO at bedtime.
Elderly: Federal OBRA guidelines recommend that the dose not exceed 0.25 mg/day PO in residents of skilled nursing facilities.
Adolescents and children: Dosage not established.
Maximum Dosage Limits:
- Adults: 6mg/day PO (immediate-release tablets or oral solution); 10 mg/day PO (extended-release tablets, Xanax® XR).
- Elderly: 0.75 mg/day PO has been suggested for anxiolytic use by Federal OBRA guidelines for skilled facilities unless higher doses are needed to maintain functional status; titrate cautiously to attain clinical goals; Federal OBRA guidelines recommend 0.25 mg/day PO for hypnotic use.
- Adolescents: 0.06 mg/kg/day PO (immediate-release tablets or oral solution) has been suggested.
- Children >= 7 years: 0.06 mg/kg/day PO (immediate-release tablets or oral solution) has been suggested.
- Children < 7 years: Safe and effective use have not been established.
Patients with hepatic impairment:
In those with alcoholic liver disease, the half-life of immediate-release alprazolam has ranged from 5.8 to 65.3 hours. Although quantitative guidelines are not available for the immediate-release product, a dosage reduction should be considered in those with hepatic impairment. For patients with severe hepatic impairment, initial doses of extended-release alprazolam are 0.5 mg PO daily; titrate as needed and tolerated to attain clinical goals.
Patients with renal impairment:
Guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
† non-FDA-approved indication
[ Last revised: 12/1/2005 10:38:00 AM ]
References
. Harrison WM, Endicott J, Nee J. Treatment of premenstrual dysphoria with alprazolam; a controlled study. Arch Gen Psychiatry 1990;47:270 - 5.
. Smith S, Rinehart JS, Ruddock VE, et al. Treatment of premenstrual syndrome with alprazolam: results of a double-blind, placebo-controlled, randomized crossover clinical trial. Obstet Gynecol 1987;70:37 - 43.
. Freeman EW, Rickels K, Sondheimer SJ et al. A double-blind trial of oral progesterone, alprazolam, and placebo in treatment of severe premenstrual syndrome. JAMA 1995;274:51 - 7.
. Simeon JG, Ferguson HB, Knott V et al. Clinical, cognitive, and neurophysiological effects of alprazolam in children and adolescents with overanxious and avoidant disorders. J Am Acad Child Adolesc Psychiatry 1992;31:29 - 33.
. Gurvich T, Cunningham JA. Appropriate Use of Psychotropic Drugs in Nursing Homes. Am Fam Physician 2000;61:1437 - 46.
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