Alprazolam for spinal muscular atrophy

Last updated Feb. 21, 2025, by Andrea Lobo, PhD
Fact-checked by José Lopes, PhD

What is alprazolam for SMA?

Alprazolam belongs to the class of benzodiazepines, approved by the U.S. Food and Drug Administration (FDA) to treat generalized anxiety disorder and panic disorder, with or without agoraphobia (an intense fear of becoming overwhelmed or unable to escape or get help) in adults.

It may also be used off-label to help manage muscle spasms and spasticity — when muscles become abnormally stiff — in people with spinal muscular atrophy (SMA).

Alprazolam is marketed as Xanax and Xanax XR by Upjohn, a Viatris Company. Generic forms are available.

Therapy snapshot

How does alprazolam work?

SMA is mainly caused by mutations in the SMN1 gene, which provides instructions to produce the survival motor neuron (SMN) protein. The loss of this protein leads to the dysfunction and death of motor neurons, the nerve cells that control voluntary movement, ultimately leading to muscle weakness and wasting.

Alprazolam binds to GABA-A protein receptors to promote their opening when binding to gamma-aminobutyric acid (GABA), a chemical messenger that decreases the likelihood of nerve cells receiving, creating, or sending nerve signals. GABA makes the nervous system less active. Alprazolam is thereby expected to act as a muscle relaxant, treating muscle spasms and spasticity.

How is alprazolam administered?

Alprazolam is available as oral tablets or as a concentrate:

• Tablets, including extended-release formulations, are available at doses ranging from 0.25 mg to 3 mg.
• Concentrate is available at 1 mg/mL.

Treatment is usually started at a dose of 0.25 to 0.5 mg, three times a day, which may be increased every three or four days. The maximum recommended daily dose for generalized anxiety disorder is 4 mg (divided among several doses).

In general, the 0.25 mg dose given two or three times daily is recommended for older patients and those with liver impairment. The recommended dose should be reduced by half in patients starting on ritonavir, an antiretroviral medication used to treat human immunodeficiency virus infection and AIDS.

In a pilot study enrolling 38 people with spasticity due to any cause, alprazolam was given at a dose of 0.5 mg for 15 days, followed by 1 mg for another 15 days. The treatment eased both spasticity and muscle spasms after one month.

Common side effects of alprazolam

The most common side effects of alprazolam reported in clinical trials enrolling adults with generalized anxiety disorder and panic disorder, but not SMA specifically, include:

• low blood pressure
• impaired coordination
• difficulty speaking causing slurred or slow speech
• increased sex drive.

Risks from using alprazolam with opioids

The FDA requires a boxed warning regarding the concomitant use of alprazolam with opioids (medications commonly used to alleviate pain), specifically the risk of abuse, misuse, and addiction, as well as dependence and withdrawal reactions. When discontinuing alprazolam usage, such patients are advised to reduce dosage gradually. Doses should be the minimum required to lower risks.

Using both types of drugs at the same time may result in profound sedation, respiratory depression (slow or shallow breathing that prevents proper gas exchange in the lungs), coma, and death. Patients should be followed for signs and symptoms of respiratory depression and sedation.

Abuse, misuse, and addiction

The use of benzodiazepines, including alprazolam, exposes users to the risk of abuse, misuse, and addiction, which can lead to overdose and death. Abuse and misuse are frequently associated with the use of medications above the maximum recommended dose, or together with other medications, alcohol, or illicit substances.

Patients with a high risk for abuse should be advised about the proper use of alprazolam and be monitored for signs of abuse.

Dependence and withdrawal

Alprazolam may lead to significant physical dependence, and its abrupt discontinuation or rapid dose reduction may lead to acute withdrawal reactions, including seizures, which can be life-threatening. Therefore, alprazolam dosage should be reduced slowly.

Driving and operating machinery

As it makes the nervous system less active, patients on alprazolam should not drive or operate any other machinery that requires being alert.

Sedation and withdrawal symptoms in newborns

Newborns of mothers treated with alprazolam late in pregnancy may experience sedation with respiratory depression, lack of energy, and low muscle tone. They may also experience withdrawal symptoms, including irritability, tremors, inconsolable crying, feeding difficulties, restlessness, and overactive bodily reflexes. Newborns exposed to alprazolam during pregnancy should be monitored for signs of sedation and withdrawal.

Drug interactions

Alprazolam is contraindicated in patients who are taking strong inhibitors of CYP3A, such as the antifungal agents ketoconazole and itraconazole, since these drugs may increase the blood levels of alprazolam.

Depression and mania

Alprazolam and other benzodiazepines may worsen depression. Also, episodes of mania and hypomania (a less severe form of mania characterized by revved-up energy or activity level, mood, or behavior) may occur in people with depression who are taking alprazolam. Therefore, limiting the total prescription size and monitoring for suicidal thoughts should be considered in patients with depression taking alprazolam.

Risk in patients with impaired respiratory function

Due to reports of death in patients with severe lung disease after starting on alprazolam, treatment should be stopped if signs of respiratory depression or temporary breathing stops occur.

Pediatric use

The safety and efficacy of alprazolam have not been determined in pediatric patients.

Use in pregnancy and breastfeeding

The use of alprazolam late in pregnancy may result in sedation and withdrawal symptoms in the newborn. Studies on the use of benzodiazepines during pregnancy do not report a clear association between the treatment and major birth defects.

Limited data have demonstrated that alprazolam may be present in human breast milk. Effects on lactation are unknown. However, there are reports of sedation, poor feeding, and poor weight gain in infants exposed to benzodiazepines through breast milk.

Breastfeeding is not recommended during treatment with alprazolam.

SMA News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.