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Midazolam vs Xanax
Introduction
Patients dealing with anxiety disorders, insomnia, or seizure disorders may find symptom relief with certain drugs that impact the central nervous system. Midazolam and Xanax are two medications often prescribed for these conditions. Both belong to a class of drugs known as benzodiazepines, which work by enhancing the effect of the neurotransmitter GABA, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant effects.
Midazolam is often used in medical procedures requiring sedation due to its rapid onset and short duration of action, and since it is also available in injectable form. On the other hand, Xanax (alprazolam) is typically used for longer-term treatment of severe generalized anxiety disorder or panic disorder given its longer half-life relative to Midazolam.
Midazolam vs Xanax Side By Side
| Attribute | Versed | Xanax |
|---|---|---|
| Brand Name | Versed | Xanax |
| Contraindications | Should not be taken with azole antifungals, macrolide antibiotics, HIV protease inhibitors among others due to potential serious interactions. | Should not be taken with azole antifungals, macrolide antibiotics, HIV protease inhibitors among others due to potential serious interactions. |
| Cost | A single 10mg/2ml vial costs approximately $20-$30. For Midazolam syrup, prices range from about $15-$70 for one 120ml bottle at a concentration of 2mg/ml. | For brand name, around $350 for 60 tablets (0.5 mg). For generic, about $10-$40 for thirty 0.5mg tablets. |
| Generic Name | Midazolam | Alprazolam |
| Most Serious Side Effect | Severe reactions affecting the nervous system, serotonin syndrome, significant and/or sudden change in mood or behavior. | Signs of an allergic reaction, unusual risk-taking behavior, thoughts of suicide, hallucinations or confusion. |
| Severe Drug Interactions | Azole antifungals, macrolide antibiotics, HIV protease inhibitors. | Azole antifungals, macrolide antibiotics, HIV protease inhibitors. |
| Typical Dose | Oral dosages range from 7.5–15 mg/day, with a starting dose usually at 7.5 mg/day. The maximum dosage should not exceed 30 mg per day. | Starts at 0.25–0.5 mg taken three times per day, may be increased every three to four days, up to a maximum total dosage of approximately 4 mg/day. |
What is Midazolam?
Midazolam (the generic name for Versed) is a drug belonging to the benzodiazepine class of sedatives, which represented a significant advancement over the first class of sedative drugs known as barbiturates. Midazolam was first approved by the FDA in 1985. It increases the effect of GABA (gamma-aminobutyric acid), an inhibitory neurotransmitter, by enhancing its activity at receptors. It is prescribed for acute management of seizures and preoperative sedation among other uses. Midazolam has a predominant influence on GABA, with only minor influence on serotonin and dopamine, resulting in fewer side effects than other sedatives that have stronger effects on these two other neurotransmitters.
Alprazolam (the generic name for Xanax) also belongs to the benzodiazepine family, but is primarily used to treat panic disorder and anxiety disorders. Similar to midazolam, alprazolam mainly influences GABA, but it tends to have more potential side effects due its more potent impact on serotonin and dopamine alongside the influence on GABA.
What conditions is Midazolam approved to treat?
Midazolam is approved for indications such as the following:
- Preoperative sedation
- As an anxiolytic (to reduce anxiety)
- To induce general anesthesia
How does midazolam exert its effect?
Midazolam helps to manage anxiety and induce sleep by increasing the efficiency of GABA, a neurotransmitter that inhibits activity in the brain. It does this by binding to the benzodiazepine site on the GABA-A receptor and enhancing the effects of naturally present GABA, which results in increased inhibitory signals throughout the central nervous system. This leads to effects such as sedation, muscle relaxation, decreased anxiety, and possibly amnesia (memory problems). Midazolam is often used for procedural sedation due to its rapid onset of action and short duration.
GABA plays an important role in mood regulation, stress response, and sleep cycle management, among other things. It's believed that individuals with high levels of anxiety may have lower levels of GABA or reduced sensitivity to GABA. Therefore, by enhancing GABA's effects, drugs like Midazolam can help patients manage their condition better.
What is Xanax?
Xanax is a brand name for alprazolam, which, like midazolam, belongs to the benzodiazepine class of drugs. It works by enhancing the activity of GABA (gamma-aminobutyric acid), an inhibitory neurotransmitter, in the central nervous system. This action results in a calming effect and helps to reduce symptoms of anxiety and panic disorders. Xanax was first approved by the FDA in 1981.
Alprazolam is potentially effective for treating depression as well. However, as it is not an SSRI antidepressant, it does not inhibit serotonin reuptake. Its lack of significant action on serotonin means that its side-effect profile differs from those of SSRIs. For example, it doesn't typically induce weight gain or sexual dysfunction as seen with many SSRIs like Prozac.
Moreover, unlike midazolam, Xanax does not usually cause significant sedation. However, drowsiness can occur, particularly at high doses or when initially starting treatment. Its effects on GABA make it particularly beneficial for individuals suffering from acute symptoms related specifically to anxiety disorders, or for those who don't respond well to SSRI antidepressant drugs.
What conditions is Xanax approved to treat?
Xanax has been authorized by the FDA for treating a variety of conditions such as:
- Anxiety disorders
- Panic disorder, with or without agoraphobia
- Anxiety related to depression
How does Xanax help with these illnesses?
Xanax, or alprazolam, is a benzodiazepine that affects gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, in the central nervous system. It works by enhancing GABA's effects to calm hyperactive mental processes. Much like midazolam, Xanax is primarily used for its ability to alleviate symptoms associated with anxiety and panic disorders due to this tranquilizing effect.
Xanax differs from midazolam in that it has a longer duration of action and can be prescribed for regular use in managing symptoms of anxiety disorders. This makes it more suitable for anxiety disorders than midazolam, which is typically used in short-term scenarios such as for preoperative sedation or acute seizure management due to its shorter half-life.
How effective are midazolam and Xanax?
Both midazolam and alprazolam (Xanax) are benzodiazepines, and are used primarily for managing anxiety disorders and panic attacks or as sedatives before medical procedures. However, they have different onsets and durations of action due to their distinct pharmacokinetic properties. Midazolam has a rapid onset of action, making it suitable for situations requiring an acute effect such as in preoperative sedation or severe agitation episodes. Alprazolam (Xanax) has a comparatively slower onset of action but longer duration of effect, which is beneficial in the longer-term management of disorders like generalized anxiety disorder.
Midazolam and alprazolam were initially approved by the FDA just 7 years apart (in 1985 and 1992, respectively). A study published in 2004 in the journal Anesthesia & Analgesia showed that both midazolam and alprazolam had similar anxiolytic effects, although midazolam was found to be slightly more potent than alprazolam.
A review article published in the Journal of Clinical Psychopharmacology reported that Xanax begins relieving symptoms within the first week of treatment, with few side effects experienced by patients. The same report also suggested that Xanax's safety profile explains its status as one of the most prescribed medications worldwide for anxiety disorders.
Multiple studies have demonstrated the effectiveness of midazolam in providing adequate sedation and amnesia during pre-operative scenarios. However, due to its fast-acting nature combined with potential adverse effects such as respiratory depression, careful monitoring is required, especially when used outside hospital settings.
These two drugs belong to the same class, but serve unique purposes. Xanax can be an optimal choice for longer-term management of anxiety as it has less severe withdrawal symptoms upon discontinuation, while midzalom is preferred for short-term treatment in cases where acute sedation is required without prolonged drowsiness.
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At what dose is midazolam typically prescribed?
Oral dosages of midazolam range from 7.5–15 mg/day, but studies have indicated that a starting dose of 7.5 mg/day is usually sufficient for treating short-term severe insomnia in most people. Elderly patients may be started on lower doses, such as 3.75 mg/day, to reduce the risk of adverse effects. In either population, dosage can be increased after a few weeks if there is no response or if symptoms persist. However, it's important to note that this medication should only be used for short-term treatment (up to two weeks) due to risk of dependency and withdrawal. The maximum dosage that should not be exceeded under any circumstances is 30 mg per day.
At what dose is Xanax typically prescribed?
Xanax treatment typically starts at a dosage of 0.25–0.5 mg taken three times per day. This dose may be gradually increased every three to four days, but by no more than 1 mg/day, up to a maximum total dosage of approximately 4 mg/day. The dose should be divided into smaller doses taken at equal intervals throughout the day. The maximum dose is largely dependent on the patient's response and tolerance, but generally should not exceed 4 mg/day divided across several doses throughout the day. Any increase beyond this level should only be done under close medical supervision due to the potential for dependence and withdrawal symptoms upon stopping taking Xanax.
What are the most common side effects of midazolam?
Common side effects of midazolam include:
- Drowsiness, somnolence (sleepiness)
- Light-headedness
- Impaired coordination/balance
- Anterograde amnesia (inability to create new memories after the event that caused the amnesia)
- Cognitive dysfunction
- Headache
- Changes in heart rate and/or blood pressure
- Nausea and vomiting
- Hiccups or coughing
- Rash or skin inflammation
- Dry mouth
It is important to note that this is not an exhaustive list of possible side effects. Everyone's body responds differently to medication, and not everyone will experience these effects. If you have any concerns about side effects you're experiencing after taking Xanax, consult your healthcare provider for further advice.
Are there any potential serious side effects for midazolam?
Although rare, Midazolam carries the risk of potentially severe side effects which would require immediate medical attention. These include:
- A significant and/or sudden change in mood or behavior, such as increased agitation, hostility, panic attacks, or suicidal thoughts
- Signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue or throat
- Vision changes like blurred vision or seeing halos around lights
- Irregular heartbeat, which might feel like a pounding or fluttering in your chest
- Shortness of breath accompanied by a sudden feeling of lightheadedness, as if you might faint
- Low sodium levels: symptoms may include headache, confusion, and slurred speech, along with severe weakness and vomiting, potentially leading to loss of coordination and feeling unsteady.
Severe reactions affecting the nervous system could present as very rigid muscles coupled with high fever and excessive sweating, potentially causing confusion. This could also be marked by uneven heartbeat, leading to tremors and a sensation akin to passing out.
Serotonin syndrome is another major risk, which can occur due to interactions with other medications you're taking simultaneously. Watch for signs including agitation, hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, and/or diarrhea.
If any such symptoms manifest after taking midazolam, seek immediate medical intervention.
What are the most common side effects of Xanax?
Xanax, a commonly prescribed benzodiazepine, may produce a range of side effects such as:
- Dry mouth and increased salivation
- Blurred vision and dizziness
- Nausea or constipation
- Changes in weight or appetite
- Difficulty sleeping (insomnia) or unusual dreams
- Shortness of breath, rapid breathing, or feeling lightheaded
- Muscle weakness, lack of balance, and poor coordination
- Memory problems and confusion
- Anxiety or agitation
- Skin rash
- Increased urination
Remember that these are potential risks, meaning that not everyone who uses Xanax will experience them. If you do experience any of these symptoms, and particularly if they persist for more than a few hours, you should seek medical advice.
Are there any potential serious side effects for Xanax?
Xanax is commonly prescribed and often effective, but it can also produce potentially serious side effects in some individuals. These may include:
- Signs of an allergic reaction such as hives, difficulty breathing or swallowing, swelling of the face, lips, tongue or throat.
- Unusual risk-taking behavior or thoughts of suicide
- Hallucinations or confusion
- Hostility and hyperactivity
- Uncontrolled muscle movements, tremor, seizure (convulsions)
- Racing heartbeat or fluttering in your chest
- A light-headed feeling, like you might pass out
These symptoms can be warning signs of more serious adverse reactions. If you experience any of these symptoms while taking Xanax, please contact your healthcare provider immediately.
Contraindications for midazolam and Xanax
Both midazolam and Xanax, as with other drugs of the benzodiazepine class of medications, can potentially worsen symptoms of depression in some individuals. If you find yourself in an increasingly negative mood or have suicidal thoughts after taking either of these medications, please reach out to your doctor or seek medical attention immediately.
Neither midazolam or Xanax should be taken if you are currently taking certain classes of medication, such as azole antifungals (for example ketoconazole), macrolide antibiotics (for instance erythromycin), or HIV protease inhibitors (like ritonavir), among others, due to potential serious interactions. This is not a complete list of potential interactions, so always inform your physician about all the drugs you're taking so they can ensure your safety. There are certain types of drugs that may need a period of time to clear from your system before initiating therapy with either midazolam or Xanax to prevent harmful or dangerous interactions.
How much do midazolam and Xanax cost?
For the brand-name versions of these drugs:
- The price of 60 tablets (0.5 mg) of Xanax, a well-known brand-name formulation of alprazolam, averages around $350, which works out to $3–6/day depending on your dosage.
- On the other hand, Versed—a popular brand name version of midazolam—is typically sold in vials instead of tablets due to its common use as an injectable sedative in medical procedures. A single vial (10mg/2mL) costs approximately $20–$30.
Therefore, if you are taking higher doses of Xanax (i.e., more than 1.5 mg/day), then Xanax tends to be more expensive than midazolam. Please remember that these medications are not direct substitutes for one another, and that cost should not be the principal factor in deciding which medication is most appropriate for you.
For the generic versions:
-
Alprazolam (generic Xanax, with the same active ingredient) costs about $10–$40 for a box of thirty (30) tablets (0.5 mg), which equates to roughly $0.33–$1.33 per day depending on the dosage.
-
For midazolam syrup (a formulation commonly used for home use), prices range from about $15–$70 for one 120 mL bottle with a concentration of 2mg/mL. Depending on usage and dosage, this would average out to around $0.25–$0.93 per day.
Again, Xanax and midazolam have different use cases. Follow your physician's guidance and do not use cost as the sole basis for decisions about which medication to take.
Popularity of midazolam and Xanax
Midazolam, available generically as well as in brand names such as Versed, was estimated to have been prescribed to about 3.5 million people in the US in 2020. Midazolam accounted for just under 7% of benzodiazepine prescriptions across the country. It is predominantly used as a sedative and anesthetic agent during medical procedures, and its use has seen a steady increase since its development.
Alprazolam, including branded versions such as Xanax, was prescribed to approximately 25 million people in the USA in 2020. In terms of overall benzodiazepine prescriptions within the US, alprazolam accounts for roughly 50%. Considering the vast selection of benzodiazepine drugs available, this statistic speaks to the relative safety and efficacy of Xanax. Alprazolam (Xanax) is mainly employed for treating anxiety disorders and panic attacks, and its prevalence has remained relatively consistent over recent years.
Conclusion
Both midazolam and Xanax (alprazolam) have established records of use in patients with anxiety. As benzodiazepines, they work by enhancing the effect of the neurotransmitter GABA that's naturally present in the central nervous system to induce a calming effect. These medications are sometimes used together, but this would only occur under careful consideration by a physician due to the potential additive sedative effects, which could be dangerous. Midazolam has a faster onset of action but shorter duration than Xanax, making it especially useful for procedures requiring quick sedation, for example as part of anesthesia protocols.
Xanax is often considered as a first-line treatment for panic disorders or generalized anxiety disorder due to its longer effect and generally lower risk of severe withdrawal upon stopping as compared to other benzodiazepines. Faster-acting midazolam is mainly indicated for pre-procedural sedation, or for acute management of seizures.
Both drugs are available in generic form, helping keep costs down for those who pay out-of-pocket. The impact of Xanax on anxiety disorders may take a few days for its effect to stabilize.
The side effect profiles are similar between Xanax and midazolam, with common side effects including drowsiness and lightheadedness. However, as compared to Xanax, midazolam's faster onset and shorter half-life can result in heavier but less-prolonged sedation. It's crucial that you closely monitor your mood when starting therapy with either of these medications, and seek medical attention immediately if you experience worsening symptoms or develop thoughts about self-harm or suicide.
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Refrences
- Berendes, E., Scherer, R., Rotthove, K., & Prien, T. (1996, June 1). Anxiolyse, Sedierung und Stre�reduktion nach oraler Pr�medikation mit Midazolam bei Erwachsenen Ein Vergleich mit Dikaliumclorazepat bzw. Plazebo. Der Anaesthesist. Springer Science and Business Media LLC.http://doi.org/10.1007/s001010050283
- Dawson, G. W., Jue, S. G., & Brogden, R. N. (1984, February). Alprazolam. Drugs. Springer Science and Business Media LLC.http://doi.org/10.2165/00003495-198427020-00002
- Gool, D. V. (2000, June). Different modes of action of alprazolam in the treatment of panic attacks. Acta Neuropsychiatrica. Cambridge University Press (CUP).http://doi.org/10.1017/s0924270800035687
- Morita, T., Tei, Y., & Inoue, S. (2003, April). Correlation of the Dose of Midazolam for Symptom Control with Administration Periods. Journal of Pain and Symptom Management. Elsevier BV.http://doi.org/10.1016/s0885-3924(02)00683-8