Alprazolam is indicated for panic disorder and the short-term symptomatic treatment of anxiety. It is listed on the Pharmaceutical Benefits Scheme (PBS) only for the treatment of panic disorder when other treatments have failed or are inappropriate. The maximum PBS-subsidised quantity for alprazolam 250mcg, 500mcg, and 1mg tablets recently reduced from 50 tablets to ten tablets. Although prescribers may apply for increased quantities when clinically required, applications for repeats will not be approved. Alprazolam 2mg is no longer subsidised on the PBS.

These restrictions follow the 2014 rescheduling of alprazolam from Schedule 4 to Schedule 8 due to safety concerns. Alprazolam has a rapid onset and offset of action, short half-life, and high potency. These characteristics confer a greater risk of dependency and withdrawal compared to other benzodiazepines. While meta-analysis does not demonstrate superior clinical efficacy, alprazolam is associated with higher morbidity and mortality in overdose and increased diversion to illicit use.

The Drug Utilisation Sub-Committee (DUSC) conducted a review in 2015 to assess the impact rescheduling had on the utilisation of alprazolam in Australia. The findings reveal a 35% reduction in prescriptions dispensed, 30% fewer patients dispensed alprazolam, 35% fewer patients initiated on alprazolam, and almost twice as many patients switched from alprazolam to diazepam or oxazepam. Estimates of private prescription use suggest a similar decline.

Alprazolam is not a first-line treatment option for panic disorder. The Therapeutic Guidelines: Psychotropic recommend cognitive behavioural therapy. If pharmacotherapy is required, a serotonin selective reuptake inhibitor (SSRI) or venlafaxine are recommended.  If alprazolam is deemed appropriate, it is only recommended for short-term use in conjunction with other therapies.

References:

  1. Department of Health. Alprazolam: Review of PBS utilisation following rescheduling to Schedule 8. Canberra: Pharmaceutical Benefits Scheme; 2015.
  2. Department of Health. Schedule of pharmaceutical benefits: summary of changes effective 1 February 2017. Canberra: Pharmaceutical Benefits Scheme; 2017.
  3. Moylan S, Staples J, Ward SA, Rogerson J, Stein DJ, Berk M. The efficacy and safety of alprazolam versus other benzodiazepines in the treatment of panic disorder. J Clin Psychopharmacol. 2011; 31(5): 647-52.
  4. Psychotropic Expert Group. Panic disorder [revised Jul 2013]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2016.

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