Alprazolam Drug Interactions You Need to Know About

Alprazolam (brand name Xanax) is an effective medication for anxiety and panic disorder, but it doesn't play well with everything. Some combinations can be uncomfortable. Others can be deadly.

This guide covers the major and moderate drug interactions for Alprazolam, along with supplements, foods, and drinks to watch out for. If you're taking Alprazolam — or about to start — read this carefully.

How Drug Interactions Work with Alprazolam

Alprazolam is broken down in your liver by an enzyme called CYP3A4. Anything that affects this enzyme can change how much Alprazolam ends up in your bloodstream:

• CYP3A4 inhibitors slow down the breakdown of Alprazolam, causing it to build up to higher levels. This increases the risk of side effects and overdose.
• CYP3A4 inducers speed up the breakdown, potentially making Alprazolam less effective.

Additionally, any substance that also depresses the central nervous system (CNS) — like opioids, alcohol, or sedating antihistamines — can amplify Alprazolam's sedating effects to dangerous levels.

Major Drug Interactions

These are the most dangerous. Some are contraindicated entirely, and others carry an FDA boxed warning.

Opioids (Boxed Warning)

The combination of Alprazolam and opioid painkillers is the single most dangerous interaction. The FDA's boxed warning states that using benzodiazepines and opioids together can cause profound sedation, respiratory depression, coma, and death.

Common opioids that interact include:

• Oxycodone (OxyContin, Percocet)
• Hydrocodone (Vicodin, Norco)
• Morphine
• Fentanyl
• Codeine
• Tramadol

If you're prescribed both an opioid and Alprazolam, your doctor should use the lowest effective doses and monitor you closely.

Strong CYP3A4 Inhibitors (Contraindicated)

These medications are not to be used with Alprazolam at all:

• Ketoconazole (Nizoral) — An antifungal medication
• Itraconazole (Sporanox) — Another antifungal

These drugs block CYP3A4 so powerfully that Alprazolam levels can skyrocket, leading to extreme sedation and respiratory depression.

Other CYP3A4 Inhibitors (Dose Reduction Needed)

These don't completely block the enzyme, but they slow it down enough that your doctor will likely need to reduce your Alprazolam dose:

• Fluconazole (Diflucan) — Antifungal
• Erythromycin and Clarithromycin (Biaxin) — Antibiotics
• Nefazodone — Antidepressant
• Fluvoxamine (Luvox) — SSRI antidepressant
• Cimetidine (Tagamet) — Heartburn medication
• Ritonavir (Norvir) — HIV protease inhibitor

Other CNS Depressants

Combining Alprazolam with other substances that slow down the brain and nervous system increases the risk of excessive sedation, breathing problems, and death:

• Alcohol — Perhaps the most common dangerous combination. Even moderate drinking while on Alprazolam can cause extreme drowsiness, impaired judgment, and respiratory depression.
• Barbiturates — Phenobarbital, butalbital
• Sedating antihistamines — Diphenhydramine (Benadryl), doxylamine (Unisom)
• Sleep medications — Zolpidem (Ambien), eszopiclone (Lunesta)

Moderate Drug Interactions

These interactions aren't immediately life-threatening but can affect how well Alprazolam works or increase side effects:

SSRIs

• Fluoxetine (Prozac) and Sertraline (Zoloft) — These common antidepressants may increase Alprazolam blood levels. Your doctor may need to monitor you more closely or adjust your dose.

Oral Contraceptives

Birth control pills may increase Alprazolam levels in the blood. The effect is usually modest, but it's worth mentioning to your doctor if you notice increased drowsiness.

Digoxin

Alprazolam may increase levels of Digoxin (Lanoxin), a heart medication. If you take both, your doctor should monitor your Digoxin levels.

CYP3A4 Inducers

These medications speed up Alprazolam metabolism, potentially making it less effective:

• Carbamazepine (Tegretol) — Seizure medication
• Rifampin (Rifadin) — Antibiotic used for tuberculosis

If you start or stop one of these medications while taking Alprazolam, your doctor may need to adjust your dose.

Supplements and Over-the-Counter Medications to Watch

It's not just prescription drugs you need to think about:

• St. John's Wort — A CYP3A4 inducer that may reduce Alprazolam effectiveness.
• Kava — Has its own sedative properties and can amplify Alprazolam's effects.
• Valerian root — Another herbal sedative that may increase drowsiness when combined with Alprazolam.
• Melatonin — While generally considered safe, combining it with Alprazolam may increase sedation.
• Diphenhydramine (Benadryl) — A CNS depressant that can significantly increase drowsiness and impairment when taken with Alprazolam.

Food and Drink Interactions

Grapefruit Juice

Grapefruit and grapefruit juice inhibit CYP3A4 in your intestines, which can increase how much Alprazolam gets absorbed into your bloodstream. The result: stronger effects and more side effects from the same dose. It's best to avoid grapefruit entirely while taking Alprazolam.

Alcohol

This bears repeating: do not drink alcohol while taking Alprazolam. Both substances depress the central nervous system, and the effects are synergistic — meaning the combined effect is greater than either one alone. Even one or two drinks can cause dangerous levels of sedation.

What to Tell Your Doctor

Before starting Alprazolam — or at any appointment where your medications are reviewed — make sure your doctor knows about:

1. Every prescription medication you take, including those prescribed by other doctors.
2. All over-the-counter medications, including allergy pills, sleep aids, and pain relievers.
3. Herbal supplements and vitamins, especially St. John's Wort, kava, and valerian.
4. Your alcohol use — be honest, even if it feels uncomfortable.
5. Any recreational drug use — especially opioids. Your doctor needs this information to keep you safe, not to judge you.
6. Changes to any medication — starting, stopping, or changing the dose of another drug can affect your Alprazolam levels.

Pharmacists are also an excellent resource. When you pick up a new medication, ask your pharmacist to check for interactions with your Alprazolam.

Final Thoughts

Alprazolam is a powerful medication that's safe and effective when used correctly — but it has more drug interactions than many people realize. The most critical ones to remember: no opioids without careful medical supervision, no Ketoconazole or Itraconazole, and no alcohol.

Keep your full medication list updated, communicate openly with your healthcare team, and don't hesitate to ask questions. For more information on Alprazolam, check our guides on side effects and uses and dosage. If you need to fill your prescription, Medfinder can help you find it in stock near you.