Benzodiazepines

Question 1

Paradoxical effects have been reported in those taking benzodiazepines. outline the symptoms of this side effect and state how it could me managed

Answer 1

1) Increase in hostility and aggression. The effects range from talkativeness and excitement to agressive and antisocial effects
2) Adjustment of dose sometimes reduces impulses

Question 2

what are the signs and symptoms of benzodiazepine overdose?

Answer 2

1) Drowsiness
2) Ataxia (affect co-ordination, balance and speech)
3) Dysarthria (difficulty speaking)
4) Nystagmus (Involuntary eye movements)
5) Occasionally respiratory depression, and coma

Question 3

How is an overdose of benzodiazepine managed?

Answer 3

Activated charcoal can be given within 1 hour of ingesting a significant quantity of benzodiazepine, provided the patient is awake and the airway is protected.

Question 4

Why should benzodiazepines be avoided in pregnancy? (unless for seizure control)

Answer 4

1) Risk of neonatal withdrawal symptoms

2) High doses in late pregnancy may cause neonatal hypothermia, hypotonia, and respiratory depression

Question 5

list some of the common indications for benzodiazepines (4)

Answer 5

1) First-line for seizures and status epilepticus
2) First-line for alcohol withdrawal reactions
3) Sedation for interventional procedures,
4) Short-term for severe, disabling or distressing anxiety or insomnia, although non-pharmacological treatment
preferable

Question 6

Outline the general MoA of benzodiazepines

Answer 6

1) Benzodiazepines facilitate and enhance binding of GABA to the GABAA receptor. This has a widespread depressant effect on synaptic transmission.
2) As a result this causes reduced anxiety, sleepiness, sedation and anticonvulsive effects.

Question 7

Outline some of the important side effects with regards to benzodiazepines

Answer 7

1) Dose-dependent drowsiness, sedation and coma
2) loss of airway reflexes can lead to airway obstruction and death.
3) If used often dependence can develop. Abrupt cessation then produces a withdrawal reaction similar to that seen with alcohol.

Question 8

How does benzodiazepine overdose differ from opioid overdoses with regards to respiratory depression?

Answer 8

1) There is relatively little cardiorespiratory depression in benzodiazepine overdose (in contrast to opioid overdose)
2) Airway obstruction caused by loss of airway reflexes in benzodiazepine overdose

Question 9

Who should benzodiazepines be used in caution with?

Answer 9

1) Elderly susceptible to the effects so use lower dose
2) Best avoided in patients with significant respiratory impairment or neuromuscular disease (e.g. myasthenia gravis)
3) Avoid in liver failure as they may precipitate hepatic encephalopathy

Question 10

Benzodiazepines should be avoided in hepatic impairment, however if essential, e.g. in alcohol withdrawal what would be the best choice and why?

Answer 10

1) lorazepam - as it depends less on the liver for its elimination
↳ in general avoid in severe impairment. Benzos with a shorter half-life are considered safer

Question 11

outline some of the important interactions with regards to benzodiazepines

Answer 11

1) Effects additive to those of other sedating drugs, including alcohol and opioids
2) Most depend on CYT P450 for elimination, so concurrent use with CYP inhibitors (e.g. amiodarone, diltiazem, macrolides, fluconazole, protease inhibitors) may increase their effects.

Question 12

The effects of the various benzodiazepines are similar. What distinguishes them is their duration of action. state which ones are suitable for the following conditions:

1) For seizures
2) Alcohol withdrawal
3) Sedation for interventional procedures
4) Insomnia and anxiety

Answer 12

1) Seizures: long-acting drug preferred-usually lorazepam (initial dose 4 mg IV) or diazepam (10 mg IV)
2) Alcohol withdrawal: oral chlordiazepoxide (also long-acting) normally used, alternatives are diazepam and lorazepam
3) short-acting: Allows rapid recovery or inadvertent over-sedation- Midazolam best
4) Insomnia and anxiety: Intermediate-acting drug at the lowest effective dose (e.g. temazepam 10 mg orally) for the shortest possible period normally < 2w

Question 13

Who should initiate IV administration of benzodiazepines and what facilities should be available?

Answer 13

Whether for seizures or sedation, should be undertaken only where facilities and expertise exist to deal with over-sedation (including airway management).

Question 14

What general counselling should patients be given with regards to benzodiazepines?

Answer 14

1) For insomnia and anxiety, advise your patient that its only a short-term measure
2) Discuss risk of dependence, which can be minimised by avoiding daily use i
3) Do not drive or operate complex or heavy machinery after taking the drug, and caution them that sometimes sleepiness may persist the following day

Question 15

outline the monitoring requirements for benzodiazepines

Answer 15

1) clinical status and vital signs are essential following IV or high-dose oral administration of a benzodiazepine
2) this includes: seizures, alcohol withdrawal and sedation
3) In insomnia and anxiety, enquiry about symptoms and side effects is the best form of monitoring

Question 16

why is it important to gradually withdraw benzodiazepines?

Answer 16

To minimise effects such as: confusion, convulsions, and toxic psychosis

Question 17

what are the symptoms of benzodiazepine withdrawal syndrome? (5)

Answer 17

1) Insomnia
2) Anxiety
3) Loss of body-weight and appetite
4) Tremor
5) Perspiration

Question 18

Benzodiazepine withdrawal syndrome may develop how long after discontinuing the following:

1) long acting drug
2) short acting

Answer 18

1) long acting- up to 3 weeks after stopping a long acting drug
2) short acting- days after stopping