BENZODIAZEPINES Flashcards
Benzodiazepines schedule
- CD 4 Part 1
Indications
- Short-term relief of anxiety
- For 2-4 weeks ONLY
- Must be severe anxiety (causing unacceptable distress)
- Anxiety may be in association with insomnia or other psychotic illness - Insomnia
- Again short-term use
- Only for severe disabling insomnia
When should benzodiazepines not be used?
- Long-term use (e.g. for chronic insomnia, or long term anxiety in which case other medicines should be used)
- Mild anxiety
- Elderly (Z-drug should be avoided as well) due to greater risk of ataxia and confusion (leading to falls and injury)
- Myasthenia gravis
- Respiratory impairment
- Sleep apnoea
Long-acting BDZ
Diazepam
Clobazam (adjunct in epilepsy)
Chlordiazepoxide (adjunct in acute alcohol withdrawal)
Alprazolam
Nitraxepam
Flurazepam
Shorter-acting BDZ
- Midazolam
- Oxazepam
- TEmazepam
- Loprazolam
- Lormetazepam
- Lorazepam
MOTELLL
Short acting - “Short-stay in a motel’
Use in elderly + liver impairment
Greater risk of withdrawal symptoms
What’s the advantage of short-acting benzo’s over long acting?
- They have little or no hangover effect the next day
- BUT…the withdrawal effects are felt straight away (e.g. a day) in comparison to long-acting (up to 3 weeks)
What are the advantages of long-acting benzo’s over short-acting?
- Short-acting are more likely to cause rebound insomnia (due to quick withdrawal effects felt)
- This continuous prescribing of short-acting can lead to long-term use and thus risk of dependence on it.
- Long-acting withdrawal effects are not felt as quickly as short-acting
- Long-acting also can last the whole day, so can treat insomnia at night AND anxiety during the day (2 in 1)
What does it mean by
“long-acting” and
“short-acting”?
Long-acting has a longer half-life
Short-acting means shorter half-life
When would it be suitable to use a short-acting benzodiazepine?
- Patients with sleep onset insomnia (so they can’t fall a sleep)
- AND when sedation during the day is undesirable
- Also elderly
When would it be suitable to use a long-acting benzodiazepine?
- Patients who get early morning wakening (so they need a long acting to get good sleep)
- If they get anxiety symptoms during the day (and need something to last the whole day)
BDZ - Side effects
Drowsiness
Light-headedness (the next day)
Confusion
Ataxia
BDZ - overdose
CRANDSS
Drowsiness
Dysarthria
Ataxia
Nystagmus
Respiratory depression
Sedation
Coma
Treatment for overdose
Activated charcoal - given within 1 hour of ingesting. patient must be awake and airway protected.
BDZ - Elderly
Should be avoided in the elderly.
Lower dose if used
Increased risk of confusion = falls and injury
BDZ - Dependence and withdrawal
Used for 4+ weeks = risk of dependence and withdrawal reaction.
Avoid long-term use
Avoid abrupt withdrawal
BDZ - Withdrawal syndrome
Occurs within a day of stopping a short-acting BDZ
Occurs within 3 weeks of stopping a long-acting BDZ
Increased:
- Anxiety
- Insomnia
- Weight loss
- Tremors
- Sweating
- Loss of appetite
- Perceptual disorders
- Tinnitus
BDZ - Withdrawal management
- Gradually convert (over 1 week) to equivalent Diazepam dose ON
- Reduce Diazepam dose by 1-2 mg increments every 2-3 weeks (up to 1/10th every 1-2 weeks for higher doses)
- Reduce diazepam dose further (can reduce in smaller steps of 500 mcg towards the end)
How long does it take to get someone off a benzodiazepine?
- If patient was taking for short term (2-4 weeks), they can usually come of it after 2-4 weeks
- However, long term users may take several months or more
BDZ - Avoid
- Respiratory impairment
- Neuromuscular disease
- Liver failure - may precipitate hepatic encelopathy. If necessary, use lorazepam (elimination is less dependent on the liver)
Which drugs should be avoided when getting someone off benzodiazepine (in order to help with withdrawal)?
- BB
- Antipsychotics
- Antidepressants
Note: This is only for
withdrawal, beta-blockers can be taken with benzo’s (according to BNF)
Interactions - avoid
- Alcohol
- Antipsychotics
- Antidepressants (e.g.
Mirtazipine) - Opiods
- Gabapentin, Pregabalin
- Phenorbarbital, primidone
Increased sedation
REMEMBER: List the equivalent benzo to diazepam 5mg
- Alprazolam 250mcg
- Clobazam 10mg
- Clonazepam 250mcg
- Flurazepam 7.5-15mg
- Chlordiazepoxide 12.5mg
- Loprazolam 0.5-1mg
- Lorazepam 500mcg
- Lormetazepam 0.5-1mg
- Nitrazepam 5mg
- Oxazepam 10mg
- Temazepam 10mg
Can dentists prescribe benzos under the NHS?
- ONLY Temazepam
- For anxious patients
undergoing dental procedures
What is the risk of using Benzos during pregnancy?
Risk of neonatal withdrawal symptoms
- Neonatal hypothermia
- Hypotonia
- Respiratory depression
Can they be used in pregnancy?
- Avoid regular use
- Only if there is a clear indication e.g. seizure control
