Benzodiazepine (short-acting) Pregnancy: Alprazolam should not be used during pregnancy unless the clinical condition of the woman requires it; if used in the last part of pregnancy avoid high doses and monitor the newborn for withdrawal symptoms and/or floppy infant syndrome. Excreted in breast milk at low level but not recommended during breast-feeding (SPC 4.6).

Alprazolam

Brand names: Xanax (US)

Alprazolam is a short-acting benzodiazepine used for the short-term management of anxiety; it is not routinely recommended in UK practice.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 250 micrograms (0.25 mg) to 500 micrograms (0.5 mg)

Route: Oral

Frequency: Three times daily, increased if required

Max: Increase if required to a total of 3 mg daily

Indication: anxiety. Elderly or in the presence of debilitating disease: 250 micrograms (0.25 mg) two to three times daily, gradually increased if needed and tolerated; lower the dose if side-effects occur. Use the lowest possible effective dose for the shortest possible time and for a maximum of 2-4 weeks; long-term treatment is not recommended and the need for continued treatment should be reassessed frequently. If longer-term treatment is necessary, intermittent treatment may be considered to minimise dependence. When a higher dose is required, increase the evening dose before the daytime doses. Patients who have not previously received psychotropic medication generally require lower doses than those who have, or those with a history of chronic alcoholism. Reduce the dose gradually to avoid withdrawal symptoms. Caution in impaired renal function and mild to moderate hepatic insufficiency; a lower dose is recommended in chronic respiratory insufficiency (SPC 4.4). Paediatric: safety and efficacy below 18 years have not been established and no data are available - use is not recommended. The US label in the same bundle differs (generalised anxiety disorder: start 0.25-0.5 mg three times daily, maximum 4 mg daily in divided doses; panic disorder: start 0.5 mg three times daily) - US dosing is not in the UK SPC and must be verified before use. eMC section 4.5 was not captured in this bundle (4.4 truncated at the source-fetch limit), so the interactions listed are largely from the US label.

Dose adjustments

Renal

Caution is recommended when treating patients with impaired renal function (and mild to moderate hepatic insufficiency); no numeric dose adjustment is stated (SPC 4.4).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to benzodiazepines, alprazolam or any of the excipients
Myasthenia gravis
Severe respiratory insufficiency
Sleep apnoea syndrome
Severe hepatic insufficiency
Concomitant use with strong CYP3A inhibitors, except ritonavir (US label section 4)

Side effects

Sedation, somnolence, ataxia, memory impairment, dysarthria, dizziness, headache (very common)
Depression (very common); confusional state, disorientation, anxiety, insomnia, nervousness, altered libido (common)
Constipation and dry mouth (very common); nausea (common)
Fatigue and irritability (very common)
Blurred vision (common); balance disorder, abnormal coordination, disturbance in attention, tremor (common)
Drug dependence and drug withdrawal syndrome, including rebound phenomena on discontinuation

Interactions

Opioids - sedation, respiratory depression, coma and death; reserve concomitant prescribing, use the lowest effective dose for the shortest duration and monitor closely (eMC 4.4; US label 7.1)
Other CNS depressants including alcohol - additive CNS depressant effects (US label 7.1)
Strong CYP3A inhibitors (e.g. ketoconazole, itraconazole) - increased alprazolam exposure; contraindicated in US labelling except ritonavir (US label 4, 7.1)
Ritonavir - halve the alprazolam dose when starting the combination, increasing to the target dose after 10-14 days (US label 2.6)
CYP3A inducers - reduced alprazolam efficacy (US label 7.1)
Digoxin - increased risk of digoxin toxicity (US label 7.1)

Clinical monograph

How it works

It enhances the inhibitory action of GABA at the GABA-A receptor, increasing chloride channel opening and producing anxiolytic, sedative and muscle-relaxant effects.

Prescribing in practice

Tolerance and dependence develop readily, so prescribe only for short periods and withdraw gradually to avoid a withdrawal syndrome including seizures.
Combining with opioids or other CNS depressants markedly increases the risk of sedation and fatal respiratory depression.
Avoid in patients with a history of substance misuse and use cautiously in the elderly and in hepatic impairment.

Monitoring

Monitor for excessive sedation, signs of dependence and the continuing indication, rather than by laboratory testing.

Counselling the patient

Do not stop suddenly; the dose must be reduced gradually under medical supervision.
Avoid alcohol and do not drive if you feel drowsy.
This medicine is intended for short-term use only.

Evidence & guidelines

MHRA and national guidance advise that benzodiazepines such as alprazolam be used only short-term at the lowest effective dose because of dependence.

Reference: NICE CG113 (GAD); MHRA Drug Safety Update Apr 2020 (benzodiazepines + opioids); Ashton Manual on benzodiazepine withdrawal; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways