What is known about alprazolam (Xanor) and nursing?

Fråga: What is known about alprazolam (Xanor) and nursing?

Sammanfattning: Due to the levels that are obtained from the breast milk and the possible effects that can occur in the neonate, it is not generally recommended to administer alprazolam to nursing mothers.

Svar: Alprazolam is a triazolo-benzodiazepine, used mainly for anxiety disorders. However, a potential problem exists when an alprazolam user becomes pregnant or wishes to nurse.

Numerous benzodiazepines have been shown to pass into the breast milk to varying degrees, with neonatal exposure averaging about 5 percent of the maternal dose (1,2). Even so, elimination of benzodiazepines in infants is slow due to immature liver metabolism, and an immature blood-brain barrier which may increase neonatal sensitivity to these compounds, and result in withdrawal symptoms (irritability, crying, sleep disturbances, and seizures) after exposure to breast milk (3). To this end, the use of benzodiazepines during breast feeding is not recommended by the American Academy of Pediatrics (4).

When discussing alprazolam exclusively, there seems to be a lack of scientific studies in lactating women who did not use the agent during pregnancy. There are numerous reports of neonatal withdrawal for infants with both intrauterine and breast milk exposure. In one case, the mother ingested 0.5 mg two-three times daily throughout her uncomplicated pregnancy and then breast-fed the infant. The infant was noted to be irritable, sleep deprived, and restless. Breast feeding was stopped a week later and yet the infant´s behavior worsened. Phenobarbital was eventually given to the infant for alprazolam withdrawal, however the patient was lost to follow-up (5).

There is, however, one case reported of a woman who began alprazolam therapy subsequent to her pregnancy. The infant received alprazolam for nine months exclusively from the breast milk. After this time, the alprazolam was tapered off over a period of two weeks. The mother reported that the child experienced some irritability and crying, which lasted for 2 weeks (5).

The only scientific studies exclusively dealing with alprazolam in nursing mothers demonstrate that the transfer of alprazolam into the breast milk happens rapidly due to a passive diffusion mechanism across the blood-milk barrier, with only the parent compound being found. The dose that the neonate receives is 0.3-5 micro gram/kg/day, or 3 per cent (body weight adjusted) of the maternal dose, with peak concentrations being noted at 60 minutes (1). 1 OO CY, Kuhn RJ, Desai N, Wright CE, McNamara PJ: Pharmacokinetics in lactating women: prediction of alprazolam transfer into milk. Br J Clin Pharmacol 1995; 40: 231-236

2 Ellenhorn´s Medical Toxicology: Diagnosis and treatment of human poisoning. 1997; 2nd ed:
3 Koren G, Maternal-fetal toxicology. A clinician´s guide. 1994; 2nd ed:
4 Young, Koda-Kimble, Applied therapeutics: the clinical use of drugs. 1996; 9th ed:

5 Anderson PO, McGuire GG: Neonatal alprazolam withdrawal - possible effects of breast feeding. DICP 1989; 23: 614