Alprazolam attenuates vasopressin-stimulated adrenocorticotropin and cortisol release: evidence for synergy between vasopressin and corticotropin-releasing hormone in humans.

Alprazolam (APZ), a triazolobenzodiazepine with unique clinical utility, has potent inhibitory effects on the human hypothalamic-pituitary-adrenal axis. Because APZ inhibits CRH secretion from isolated rat hypothalami and inhibits the probable CRH-mediated effect of naloxone on ACTH release, it is likely APZ acts as an inhibitor of hypothalamic CRH release in humans. The two principal physiological ACTH secretagogues are CRH and arginine vasopressin (AVP). We studied the ACTH and cortisol responses to an ACTH-releasing dose of AVP with and without preadministration of APZ in humans. Our hypothesis was that acute CRH deprivation by APZ would attenuate the ACTH response to vasopressin, as CRH and AVP act synergistically to control ACTH release. This synergy may depend on activation of subpopulations of corticotropes, some of which require both CRH and AVP together to elicit an ACTH response and/or intracellular "cross-talk" between second messenger pathways stimulated by the secretagogues. APZ (2 mg, orally) was given to eight healthy volunteers 90 min before AVP (0.0143 IU/kg BW, iv) in a randomized, double blind, placebo-controlled design during afternoon studies. ACTH and cortisol levels were measured at frequent intervals from 60 min before to 120 min after AVP injection. APZ reduced the mean integrated ACTH and cortisol responses to AVP by 67% and 70% respectively [ACTH, 161.6 +/- 59.7 vs. 53.0 +/- 20.9 pmol/min.L (P = 0.022); cortisol, 9314 +/- 3310 vs. 2763 +/- 1472 nmol/min.L (P = 0.020, AVP vs. APZ/AVP, respectively)]. APZ reduced the mean peak ACTH and cortisol responses to AVP by 57% (P = 0.023) and 40% (P = 0.0012), respectively. AVP levels were not significantly different in those who received APZ or placebo. This study provides further evidence of the potent inhibitory effects of APZ on ACTH and cortisol release in humans and is the first to find that APZ inhibits AVP-stimulated ACTH and cortisol release. This study also suggests that CRH/AVP synergy is an important physiological mechanism for ACTH release in humans, as indicated by the blunted ACTH response to AVP after APZ-mediated acute CRH deprivation. Inhibition of the pituitary-adrenal axis by APZ may explain its unique efficacy in psychiatric disorders thought to be associated with dysregulation of hypothalamic CRH release.