Alprazolam (alprazolam 1 mg) Dailymed

Description

Alprazolam is a triazolo analog of the 1,4 benzodiazepine class of central nervous system-active compounds.

The chemical name of alprazolam is 8-chloro-1-methyl-6-phenyl-4 -s-triazolo [4,3-α] [1,4] benzodiazepine, and its structural formula is: H
Structural formula
Alprazolam is a white to off-white crystalline powder, which is soluble in alcohol but which has no appreciable solubility in water at physiological pH.

Each tablet, for oral administration, contains 0.25 mg, 0.5 mg, 1 mg, and 2 mg of alprazolam. The 2 mg tablets are multiscored, and may be divided in half to provide two 1 mg segments, or quarters to provide four 0.5 mg segments.

In addition, each tablet contains the following inactive ingredients: colloidal silicon dioxide, corn starch, docusate sodium, lactose (hydrous), magnesium stearate, microcrystalline cellulose, and sodium benzoate. The 0.5 mg tablet also contains FD&C yellow #6 aluminum lake (sunset yellow lake). The 1 mg tablet also contains FD&C blue #2 aluminum lake. The 2 mg tablet also contains D&C yellow #10 aluminum lake.

Clinical Pharmacology

CNS agents of the 1,4 benzodiazepine class presumably exert their effects by binding at stereo specific receptors at several sites within the central nervous system. Their exact mechanism of action is unknown. Clinically, all benzodiazepines cause a dose-related central nervous system depressant activity varying from mild impairment of task performance to hypnosis.

Following oral administration, alprazolam is readily absorbed. Peak concentrations in the plasma occur in one to two hours following administration. Plasma levels are proportionate to the dose given; over the dose range of 0.5 to 3 mg, peak levels of 8.0 to 37 ng/mL were observed. Using a specific assay methodology, the mean plasma elimination half-life of alprazolam has been found to be about 11.2 hours (range: 6.3 to 26.9 hours) in healthy adults.

The predominant metabolites are α -hydroxy-alprazolam and a benzophenone derived from alprazolam. The biological activity of α -hydroxy-alprazolam is approximately one-half that of alprazolam. The benzophenone metabolite is essentially inactive. Plasma levels of these metabolites are extremely low, thus precluding precise pharmacokinetic description. However, their half-lives appear to be of the same order of magnitude as that of alprazolam. Alprazolam and its metabolites are excreted primarily in the urine.

The ability of alprazolam to induce human hepatic enzyme systems has not yet been determined. However, this is not a property of benzodiazepines in general. Further, alprazolam did not affect the prothrombin or plasma warfarin levels in male volunteers administered sodium warfarin orally.

, alprazolam is bound (80 percent) to human serum protein. In vitro

Changes in the absorption, distribution, metabolism and excretion of benzodiazepines have been reported in a variety of disease states including alcoholism, impaired hepatic function and impaired renal function. Changes have also been demonstrated in geriatric patients. A mean half-life of alprazolam of 16.3 hours has been observed in healthy elderly subjects (range: 9.0 to 26.9 hours, n=16) compared to 11.0 hours (range: 6.3 to 15.8 hours, n=16) in healthy adult subjects. In patients with alcoholic liver disease the half-life of alprazolam ranged between 5.8 and 65.3 hours (mean: 19.7 hours, n=17) as compared to between 6.3 and 26.9 hours (mean=11.4 hours, n=17) in healthy subjects. In an obese group of subjects the half-life of alprazolam ranged between 9.9 and 40.4 hours (mean=21.8 hours, n=12) as compared to between 6.3 and 15.8 hours (mean=10.6 hours, n=12) in healthy subjects.

Because of its similarity to other benzodiazepines, it is assumed that alprazolam undergoes transplacental passage and that it is excreted in human milk.

Indications And Usage

Alprazolam tablets are indicated for the management of anxiety disorder (a condition corresponding most closely to the APA Diagnostic and Statistical Manual (DSM-III-R) diagnosis of generalized anxiety disorder) or the short-term relief of symptoms of anxiety. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic.

Generalized anxiety disorder is characterized by unreaulic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances, for a period of six months or longer, during which the person has been bothered more days than not by these concerns. At least 6 of the following 18 symptoms are often present in these patients: (trembling, twitching, or feeling shaky; muscle tension, aches, or soreness; restlessness; easy fatigability); (shortness of breath or smothering sensations; palpitations or accelerated heart rate; sweating, or cold clammy hands; dry mouth; dizziness or light-headedness; nausea, diarrhea, or other abdominal distress; flushes or chills; frequent urination; trouble swallowing or ‘lump in throat’); (feeling keyed up or on edge; exaggerated startle response; difficulty concentrating or ‘mind going blank’ because of anxiety; trouble falling or staying asleep; irritability). These symptoms must not be secondary to another psychiatric disorder or caused by some organic factor. Motor Tension Autonomic Hyperactivity Vigilance and Scanning

Anxiety associated with depression is responsive to alprazolam.

Alprazolam tablets are also indicated for the treatment of panic disorder, with or without agoraphobia.

Studies supporting this claim were conducted in patients whose diagnoses corresponded closely to the DSM-III-R criteria for panic disorder (see ). CLINICAL STUDIES

Panic disorder is an illness characterized by recurrent panic attacks. The panic attacks, at least initially, are unexpected. Later in the course of this disturbance certain situations, eg, driving a car or being in a crowded place, may become associated with having a panic attack. These panic attacks are not triggered by situations in which the person is the focus of others’ attention (as in social phobia). The diagnosis requires four such attacks within a four week period, or one or more attacks followed by at least a month of persistent fear of having another attack. The panic attacks must be characterized by at least four of the following symptoms: dyspnea or smothering sensations; dizziness, unsteady feelings, or faintness; palpitations or tachycardia; trembling or shaking; sweating; choking; nausea or abdominal distress; depersonalization or derealization; paresthesias; hot flashes or chills; chest pain or discomfort; fear of dying; fear of going crazy or of doing something uncontrolled. At least some of the panic attack symptoms must develop suddenly, and the panic attack symptoms must not be attributed to some know organic factors. Panic disorder is frequently associated with some symptoms of agoraphobia.

Demonstrations of the effectiveness of alprazolam by systematic clinical study are limited to four months duration for anxiety disorder and four to ten weeks duration for panic disorder; however, patients with panic disorder have been treated on an open basis for up to eight months without apparent loss of benefit. The physician should periodically reassess the usefulness of the drug for the individual patient.

Contraindications

Alprazolam tablets are contraindicated in patients with known sensitivity to this drug or other benzodiazepines. Alprazolam may be used in patients with open angle glaucoma who are receiving appropriate therapy, but is contraindicated in patients with acute narrow angle glaucoma.

Alprazolam is contraindicated with ketoconazole and intraconazole, since these medications significantly impair the oxidative metabolism mediated by cytochrome P450 3A (CYP 3A) (see and ). WARNINGS PRECAUTIONS-Drug Interactions

Warnings

Precautions

General

If alprazolam is to be combined with other psychotropic agents or anticonvulsant drugs, careful consideration should be given to the pharmacology of the agents to be employed, particularly with compounds which might potentiate the action of benzodiazepines (see ). Drug Interactions

As with other psychotropic medications, the usual precautions with respect to administration of the drug and size of the prescription are indicated for severely depressed patients or those in whom there is reason to expect concealed suicidal ideation or plans.

It is recommended that the dosage be limited to the smallest effective dose to preclude the development of ataxia or oversedation which may be a particular problem in elderly or debilitated patients. (see ). The usual precautions in treating patients with impaired renal, hepatic or pulmonary function should be observed. There have been rare reports of death in patients with severe pulmonary disease shortly after the initiation of treatment with alprazolam. A decreased systemic alprazolam elimination rate (eg, increased plasma half-life) has been observed in both alcoholic liver disease patients and obese patients receiving alprazolam (see ). DOSAGE AND ADMINISTRATION CLINICAL PHARMACOLOGY

Episodes of hypomania and mania have been reported in association with the use of alprazolam in patients with depression.

Alprazolam has a weak uricosuric effect. Although other medications with weak uricosuric effect have been reported to cause acute renal failure, there have been no reported instances of acute renal failure attributable to therapy with alprazolam.

Information for Patients

For All Users Of Alprazolam:

To assure safe and effective use of benzodiazepines, all patients prescribed alprazolam should be provided with the following guidance. In addition, panic disorder patients, for whom doses greater than 4 mg/day are typically prescribed, should be advised about the risks associated with the use of higher doses.

• 
  Inform your physician about any alcohol consumption and medicine you are taking now, including medication you may buy without a prescription. Alcohol should generally not be used during treatment with benzodiazepines.
  
• 
  Not recommended for use in pregnancy. Therefore, inform your physician if you are pregnant, if you are planning to have a child, or if you become pregnant while you are taking this medication.
  
• 
  Inform your physician if you are nursing.
  
• 
  Until you experience how this medication affects you, do not drive a car or operate potentially dangerous machinery, etc.
  
• 
  Do not increase the dose even if you think the medication “does not work anymore” without consulting your physician. Benzodiazepines, even when used as recommended, may produce emotional and/or physical dependence.
  
• 
  Do not stop taking this medication abruptly or decrease the dose without consulting your physician, since withdrawal symptoms can occur.
  

Additional Advice For Panic Disorder Patients:

The use of alprazolam at doses greater than 4 mg/day, often necessary to treat panic disorder, is accompanied by risks that you need to carefully consider. When used at doses greater than 4 mg/day, which may or may not be required for your treatment, alprazolam has the potential to cause severe emotional and physical dependence in some patients and these patients may find it exceedingly difficult to terminate treatment. In two controlled trials of six to eight weeks duration where the ability of patients to discontinue medication was measured, 7 to 29% of patients treated with alprazolam did not completely taper off therapy. In a controlled postmarketing discontinuation study of panic disorder patients, the patients treated with doses of alprazolam greater than 4 mg/day had more difficulty tapering to zero dose than patients treated with less than 4 mg/day. In all cases, it is important that your physician help you discontinue this medication in a careful and safe manner to avoid overly extended use of alprazolam.

In addition, the extended use at doses greater than 4 mg/day appears to increase the incidence and severity of withdrawal reactions when alprazolam is discontinued. These are generally minor but seizure can occur, especially if you reduce the dose too rapidly or discontinue the medication abruptly. Seizure can be life-threatening.

Laboratory Tests

Laboratory tests are not ordinarily required in otherwise healthy patients.

Drug Interactions

The benzodiazepines, including alprazolam, produce additive CNS depressant effects when coadministered with other psychotropic medications, anticonvulsants, antihistaminics, ethanol and other drugs which themselves produce CNS depression.

The steady state plasma concentrations of imipramine and desipramine have been reported to be increased an average of 31% and 20%, respectively, by the concomitant administration of alprazolam in doses up to 4 mg/day. The clinical significance of these changes is unknown.

Drugs That Inhibit Alprazolam Metabolism Via Cytochrome P450 3A:

The initial step in alprazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP 3A). Drugs which inhibit this metabolic pathway may have a profound effect on the clearance of alprazolam (see and for additional drugs of this type. CONTRAINDICATIONS WARNINGS

Drugs Demonstrated To Be CYP 3A Inhibitors Of Possible Clinical Significance On The Basis Of Clinical Studies Involving Alprazolam (Caution Is Recommended During Coadministration With Alprazolam:

--Coadministration of fluoxetine with alprazolam increased the maximum plasma concentration of alprazolam by 46%, decreased clearance by 21%, increased half-life by 17%, and decreased measured psychomotor performance. Fluoxetine

--Coadministration of propoxyphene decreased the maximum plasma concentration of alprazolam by 6%, decreased clearance by 38%; and increased half-life by 58%. Propoxyphene

--Coadministration of oral contraceptives increased the maximum plasma concentration of alprazolam by 18%, decreased clearance by 22%, and increased half-life by 29%. Oral contraceptives

Drugs And Other Substances Demonstrated To Be CYP 3A Inhibitors On The Basis Of Clinical Studies Involving Benzodiazepines Metabolized Similarly To Alprazolam Or On The Basis Of Studies With Alprazolam Or Other Benzodiazepines (Caution Is Recommended During Coadministration With Alprazolam): In Vitro

Available data from clinical studies of benzodiazepines other than alprazolam suggest a possible drug interaction with alprazolam for the following: diltiazem, isoniazid, macrolide antibiotics such as erythromycin and clarithromycin, and grapefruit juice. Data from studies of alprazolam suggest a possible drug interaction with alprazolam for the following: sertraline and paroxetine. Data from studies of benzodiazepines other than alprazolam suggest a possible drug interaction for the following: ergotamine, cyclosporine, amiodarone, nicardipine, and nifedipine. Caution is recommended during the coadministration of any of these with alprazolam (see ). in vitro in vitro WARNINGS

Drug/Laboratory Test Interactions

Although interactions between benzodiazepines and commonly employed clinical laboratory tests have occasionally been reported, there is no consistent pattern for a specific drug or specific test.

Carcinogenesis, Mutagenesis, Impairment of Fertility

No evidence of carcinogenic potential was observed during 2-year bioassay studies of alprazolam in rats at doses up to 30 mg/kg/day (150 times the maximum recommended daily human dose of 10 mg/day) and in mice at doses up to 10 mg/kg/day (50 times the maximum recommended daily human dose).

Alprazolam was not mutagenic in the rat micronucleus test at doses up to 100 mg/kg, which is 500 times the maximum recommended daily human dose of 10 mg/day. Alprazolam also was not mutagenic in the DNA Damage/Alkaline Elution Assay or the Ames Assay. in vitro

Alprazolam produced no impairment of fertility in rats at doses up to 5 mg/kg/day, which is 25 times the maximum recommended daily human dose of 10 mg/day.

Pregnancy

Teratogenic Effects

(see section) Pregnancy category D: WARNINGS

Nonteratogenic Effects

It should be considered that the child born of a mother who is receiving benzodiazepines may be at some risk for withdrawal symptoms from the drug during the postnatal period. Also, neonatal flaccidity and respiratory problems have been reported in children born of mothers who have been receiving benzodiazepines.

Labor and Delivery

Alprazolam has no established use in labor or delivery.

Nursing Mothers

Benzodiazepines are known to be excreted in human milk. It should be assumed that alprazolam is as well. Chronic administration of diazepam to nursing mothers has been reported to cause their infants to become lethargic and to lose weight. As a general rule, nursing should not be undertaken by mothers who must use alprazolam.

Pediatric Use

Safety and effectiveness of alprazolam in individuals below 18 years of age have not been established.

Geriatric Use

The elderly may be more sensitive to the effects of benzodiazepines. They exhibit higher plasma alprazolam concentrations due to reduced clearance of the drug as compared with a younger population receiving the same doses. The smallest effective dose of alprazolam should be used in the elderly to preclude the development of ataxia and oversedation (see and ). CLINICAL PHARMACOLOGY DOSAGE AND ADMINISTRATION

Adverse Reactions

Side effects to alprazolam, if they occur, are generally observed at the beginning of therapy and usually disappear upon continued medication. In the usual patient, the most frequent side effects are likely to be an extension of the pharmacological activity of alprazolam, eg, drowsiness or light-headedness.

The data cited in the two tables below are estimates of untoward clinical event incidence among patients who participated under the following clinical conditions: relatively short duration (ie, four weeks) placebo-controlled clinical studies with dosages up to 4 mg/day of alprazolam (for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety) and short-term (up to ten weeks) placebo-controlled clinical studies with dosages up to 10 mg/day of alprazolam in patients with panic disorder, with or without agoraphobia.

These data cannot be used to predict precisely the incidence of untoward events in the course of usual medical practice where patient characteristics, and other factors often differ from those in clinical trials. These figures cannot be compared with those obtained from other clinical studies involving related drug products and placebo as each group of drug trials are conducted under a different set of conditions.

Comparison of the cited figures, however, can provide the prescriber with some basis for estimating the relative contributions of drug and non-drug factors to the untoward event incidence in the population studied. Even this use must be approached cautiously, as a drug may relieve a symptom in one patient but induce it in others.

(For example, an anxiolytic drug may relieve dry mouth [a symptom of anxiety] in some subjects but induce it [an untoward event] in others.)

Additionally, for anxiety disorders the cited figures can provide the prescriber with an indication as to the frequency with which physician intervention (eg, increased surveillance, decreased dosage or discontinuation of drug therapy) may be necessary because of the untoward clinical event.

ANXIETY DISORDERS

	Treatment-Emergent Symptom Incidence†			Incidence of Intervention Because of Symptom
*None reported
†Events reported by 1% or more of alprazolam patients are included
	Alprazolam	Placebo		Alprazolam
Number of Patients	565	505		565
% of Patients Reporting:
CENTRAL NERVOUS SYSTEM
Drowsiness	41.0	21.6		15.1
Light-headedness	20.8	19.3		1.2
Depression	13.9	18.1		2.4
Headache	12.9	19.6		1.1
Confusion	9.9	10.0		0.9
Insomnia	8.9	18.4		1.3
Nervousness	4.1	10.3		1.1
Syncope	3.1	4.0		*
Dizziness	1.8	0.8		2.5
Akathisia	1.6	1.2		*
Tiredness/Sleepiness	*	*		1.8
GASTROINTESTINAL
Dry Mouth	14.7	13.3		0.7
Constipation	10.4	11.4		0.9
Diarrhea	10.1	10.3		1.2
Nausea/Vomiting	9.6	12.8		1.7
Increased Salivation	4.2	2.4		*
CARDIOVASCULAR
Tachycardia/Palpitations	7.7	15.6		0.4
Hypotension	4.7	2.2		*
SENSORY
Blurred Vision	6.2	6.2		0.4
MUSCULOSKELETAL
Rigidity	4.2	5.3		*
Tremor	4.0	8.8		0.4
CUTANEOUS
Dermatitis/Allergy	3.8	3.1		0.6
OTHER
Nasal Congestion	7.3	9.3		*
Weight Gain	2.7	2.7		*
Weight Loss	2.3	3.0		*

In addition to the relatively common (ie, greater than 1%) untoward events enumerated in the table above, the following adverse events have been reported in association with the use of benzodiazepines: dystonia, irritability, concentration difficulties, anorexia, transient amnesia or memory impairment, loss of coordination, fatigue, seizures, sedation, slurred speech, jaundice, musculoskeletal weakness, pruritus, diplopia, dysarthria, changes in libido, menstrual irregularities, incontinence and urinary retention.

PANIC DISORDER

		Treatment-Emergent Symptom Incidence*
*Events reported by 1% or more of alprazolam patients are included.
		Alprazolam	Placebo
Number of Patients		1388	1231
% of Patients Reporting:
Central Nervous System
Drowsiness		76.8	42.7
Fatigue and Tiredness		48.6	42.3
Impaired Coordination		40.1	17.9
Irritability		33.1	30.1
Memory Impairment		33.1	22.1
Light-headedness/Dizziness		29.8	36.9
Insomnia		29.4	41.8
Headache		29.2	35.6
Cognitive Disorder		28.8	20.5
Dysarthria		23.3	6.3
Anxiety		16.6	24.9
Abnormal Involuntary Movement		14.8	21.0
Decreased Libido		14.4	8.0
Depression		13.8	14.0
Confusional State		10.4	8.2
Muscular Twitching		7.9	11.8
Increased Libido		7.7	4.1
Change in Libido (Not Specified)		7.1	5.6
Weakness		7.1	8.4
Muscle Tone Disorders		6.3	7.5
Syncope		3.8	4.8
Akathisia		3.0	4.3
Agitation		2.9	2.6
Disinhibition		2.7	1.5
Paresthesia		2.4	3.2
Talkativeness		2.2	1.0
Vasomotor Disturbances		2.0	2.6
Derealization		1.9	1.2
Dream Abnormalities		1.8	1.5
Fear		1.4	1.0
Feeling Warm		1.3	0.5
Gastrointestinal
Decreased Salivation		32.8	34.2
Constipation		26.2	15.4
Nausea/Vomiting		22.0	31.8
Diarrhea		20.6	22.8
Abdominal Distress		18.3	21.5
Increased Salivation		5.6	4.4
Cardio-Respiratory
Nasal Congestion		17.4	16.5
Tachycardia		15.4	26.8
Chest Pain		10.6	18.1
Hyperventilation		9.7	14.5
Upper Respiratory Infection		4.3	3.7
Sensory
Blurred Vision		21.0	21.4
Tinnitus		6.6	10.4
Musculoskeletal
Muscular Cramps		2.4	2.4
Muscle Stiffness		2.2	3.3
Cutaneous
Sweating		15.1	23.5
Rash		10.8	8.1
Other
Increased		32.7	22.8
Decreased Appetite		27.8	24.1
Weight Gain		27.2	17.9
Weight Loss		22.6	16.5
Micturition Difficulties		12.2	8.6
Menstrual Disorders		10.4	8.7
Sexual Dysfunction		7.4	3.7
Edema		4.9	5.6
Incontinence		1.5	0.6
Infection		1.3	1.7

In addition to the relatively common (ie, greater than 1%) untoward events enumerated in the table above, the following adverse events have been reported in association with the use of alprazolam: seizures, hallucinations, depersonalization, taste alterations, diplopia, elevated bilirubin, elevated hepatic enzymes, and jaundice.

There have also been reports of withdrawal seizures upon rapid decrease or abrupt discontinuation of alprazolam (see ). WARNINGS

To discontinue treatment in patients taking alprazolam, the dosage should be reduced slowly in keeping with good medical practice. It is suggested that the daily dosage of alprazolam be decreased by no more than 0.5 mg every three days (see ). Some patients may benefit from an even slower dosage reduction. In a controlled postmarketing discontinuation study of panic disorder patients which compared this recommended taper schedule with a slower taper schedule, no difference was observed between the groups in the proportion of patients who tapered to zero dose; however, the slower schedule was associated with a reduction in symptoms associated with a withdrawal syndrome. DOSAGE AND ADMINISTRATION

Panic disorder has been associated with primary and secondary major depressive disorders and increased reports of suicide among untreated patients. Therefore, the same precaution must be exercised when using doses of alprazolam greater than 4 mg/day in treating patients with panic disorders as is exercised with the use of any psychotropic drug in treating depressed patients or those in whom there is reason to expect concealed suicidal ideation or plans.

As with all benzodiazepines, paradoxical reactions such as stimulation, increased muscle spasticity, sleep disturbances, hallucinations and other adverse behavioral effects such as agitation, rage, irritability, and aggressive or hostile behavior have been reported rarely. In many of the spontaneous case reports of adverse behavioral effects, patients were receiving other CNS drugs concomitantly and/or were described as having underlying psychiatric conditions. Should any of the above events occur, alprazolam should be discontinued. Isolated published reports involving small numbers of patients have suggested that patients who have borderline personality disorder, a prior history of violent or aggressive behavior, or alcohol or substance abuse may be at risk for such events. Instances of irritability, hostility, and intrusive thoughts have been reported during discontinuation of alprazolam in patients with posttraumatic stress disorder.

Laboratory analyses were performed on all patients participating in the clinical program for alprazolam. The following incidences of abnormalities shown below were observed in patients receiving alprazolam and in patients in the corresponding placebo group. Few of these abnormalities were considered to be of physiological significance.

			Placebo
	LOW	HIGH	LOW	HIGH
*Less Than 1%
HEMATOLOGY
Hematocrit	*	*	*	*
Hemoglobin	*	*	*	*
Total WBC Count	1.4	2.3	1.0	2.0
Neutrophil Count	2.3	3.0	4.2	1.7
Lymphocyte Count	5.5	7.4	5.4	9.5
Monocyte Count	5.3	2.8	6.4	*
Eosinophil Count	3.2	9.5	3.3	7.2
Basophil Count	*	*	*	*
URINALYSIS
Albumin	--	*	--	*
Sugar	--	*	--	*
RBC/HPF	--	3.4	--	5.0
WBC/HPF	--	25.7	--	25.9
BLOOD CHEMISTRY
Creatinine	2.2	1.9	3.5	1.0
Bilirubin	*	1.6	*	*
SGOT	*	3.2	1.0	1.8
Alkaline Phosphatase	*	1.7	*	1.8

When treatment with alprazolam is protracted, periodic blood counts, urinalysis and blood chemistry analyses are advisable.

Minor changes in EEG patterns, usually low-voltage fast activity have been observed in patients during therapy with alprazolam and are of no known significance.

Various adverse drug reactions have been reported in association with the use of alprazolam since market introduction. The majority of these reactions were reported through the medical event voluntary reporting system. Because of the spontaneous nature of the reporting of medical events and the lack of controls, a causal relationship to the use of alprazolam cannot be readily determined. Reported events include: liver enzyme elevations, hepatitis, hepatic failure, Stevens-Johnson syndrome, hyperprolactinemia, gynecomastia and galactorrhea. Post Introduction Reports: