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Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to the CNS depressant activity of benzodiazepines even after low doses. Manifestations include ataxia, oversedation and hypotension. Therefore, medication should be administered with caution to these patients, particularly if a drop in blood pressure might lead to cardiac complications. Initial doses should be low and increments should be made gradually, depending on the response of the patient, in order to avoid oversedation, neurological impairment and other possible adverse reactions.

Alprazolam should not be administered to individuals prone to drug abuse. Caution should be observed in all patients who are considered to have potential for psychological dependence. Withdrawal symptoms have been observed after abrupt discontinuation of benzodiazepines. These include irritability, nervousness, insomnia, agitation, tremors, convulsions, diarrhea, abdominal cramps, vomiting and mental impairment. Since these symptoms may be similar to those for which the patient is being treated, it may appear that he has suffered a relapse upon discontinuation. It is suggested that alprazolam should be withdrawn gradually if the individual is suspected of having become dependent, or the drug perhaps has been used in prolonged high doses.

Suicidal tendencies may be present in patients with emotional disorders, particularly when depressed and that protective measures and appropriate treatment may be necessary and should be instituted without delay.

Alprazolam should not be used in patients suspected of having psychotic tendencies since excitement and other paradoxical reactions can result from the use of anxiolytic-sedatives in these patients. As with other benzodiazepines, alprazolam should not be used in individuals with physiological anxiety or normal stress of daily living but only in the presence of disabling manifestations of an appropriate pathological anxiety disorder.

These drugs are not effective in patients with characterological and personality disorders or those with obsessive compulsive disorders. Alprazolam is not recommended for the management of depressive or psychotic disorders.

If treatment is necessary in patients with impaired hepatic or renal function, therapy should be initiated at a very low dose and the dosage increased only to the extent that it is compatible with the degree of residual function of these organs.

If alprazolam is administered for repeated cycles of therapy, periodic blood counts and liver function tests are advisable.

Since benzodiazepines may occasionally exacerbate grand mal seizures, caution is required when used in epileptic patients and an adjustment may be necessary in their anticonvulsive medication. Abrupt withdrawal of alprazolam should be avoided.

Benzodiazepines may potentiate or interact with effects of other CNS acting drugs such as alcohol, narcotics, barbiturates, nonbarbiturate hypnotics, antihistamines, phenothiazines, butyrophenones, MAO inhibitors, tricyclic antidepressants and anticonvulsants. Therefore, if alprazolam is to be combined with other drugs acting on the CNS, careful consideration should be given to the pharmacology of the agent involved because of the possible additive or potentiating effects. Patients should also be advised against the simultaneous use of other CNS depressant drugs and should be cautioned not to take alcohol during the administration of alprazolam.