THERAPEUTICS

Brands

• Xanax, Xanax XR
• see index for additional brand names

Generic?

• Yes

Class

• Benzodiazepine (anxiolytic)

Commonly Prescribed for

• (bold for FDA approved)
• Generalized anxiety disorder (IR)
• Panic disorder (IR and XR)
• Other anxiety disorders
• Anxiety associated with depression
• Premenstrual dysphoric disorder
• Irritable bowel syndrome and other somatic symptoms associated with anxiety disorders
• Insomnia
• Acute mania (adjunctive)
• Acute psychosis (adjunctive)
• Catatonia

How The Drug Works

• Binds to benzodiazepine receptors at the GABA-A ligand-gated chloride channel complex
• Enhances the inhibitory effects of GABA
• Boosts chloride conductance through GABA-regulated channels
• Inhibits neuronal activity presumably in amygdala-centered fear circuits to provide therapeutic benefits in anxiety disorders

How Long Until It Works

• Some immediate relief with first dosing is common; can take several weeks with daily dosing for maximal therapeutic benefit

If It Works

• For short-term symptoms of anxiety – after a few weeks, discontinue use or use on an “as-needed” basis
• For chronic anxiety disorders, the goal of treatment is complete remission of symptoms as well as prevention of future relapses
• For chronic anxiety disorders, treatment most often reduces or even eliminates symptoms, but not a cure since symptoms can recur after medicine stopped
• For long-term symptoms of anxiety, consider switching to an SSRI or SNRI for long-term maintenance
• If long-term maintenance with a benzodiazepine is necessary, continue treatment for 6 months after symptoms resolve, and then taper dose slowly
• If symptoms reemerge, consider treatment with an SSRI or SNRI, or consider restarting the benzodiazepine; sometimes benzodiazepines have to be used in combination with SSRIs or SNRIs for best results

If It Doesn’t Work

• Consider switching to another agent or adding an appropriate augmenting agent
• Consider psychotherapy, especially cognitive behavioral psychotherapy
• Consider presence of concomitant substance abuse
• Consider presence of alprazolam abuse
• Consider another diagnosis, such as a comorbid medical condition

Best Augmenting Combos for Partial Response or Treatment Resistance

• Benzodiazepines are frequently used as augmenting agents for antipsychotics and mood stabilizers in the treatment of psychotic and bipolar disorders
• Benzodiazepines are frequently used as augmenting agents for SSRIs and SNRIs in the treatment of anxiety disorders
• Not generally rational to combine with other benzodiazepines
• Caution if using as an anxiolytic concomitantly with other sedative hypnotics for sleep

Tests

• In patients with seizure disorders, concomitant medical illness, and/or those with multiple concomitant long-term medications, periodic liver tests and blood counts may be prudent