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BENZODIAZEPINE. By Hena Jawaid. Benzodiazepines. Benzodiazepines are divided into two groups depending on their half-life. 1. Hypnotics (short half-life) 2. Anxiolytics (long half-life). Benzodiazepines. Other uses (than hypnosis and anxiety):
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BENZODIAZEPINE By Hena Jawaid
Benzodiazepines Benzodiazepines are divided into two groups depending on their half-life. 1. Hypnotics (short half-life) 2. Anxiolytics (long half-life)
Benzodiazepines Other uses (than hypnosis and anxiety): • epilepsy • severe muscle spasm • Surgical procedures • rapid tranquillization
Anxiolytic effect • BZ prescription should not be for longer than 1 month. • NICE does not recommend use of BZ in panic disorder. • BZ should be avoided in those with major personality problems or with H/O substance misuse. • BZ has no effect on bereavement.
Hypnotic effect • Physical causes (pain, dyspnoea) or substance misuse (high caffeine usage) should be excluded before a hypnotic use. • Avoid prescription of hypnotics on DC.
Depression • BZ are not a treatment for major depressive disorder* • NICE found no evidence in the initial treatment of depression. * (National Service Framework for Mental Health)
Side effects • Headaches, confusion, ataxia, dysarthria, blurred vision, gastrointestinal disturbances, jaundice, paradoxical excitement, anterograde amnesia, dis-inhibition & risk of hip fracture in the elderly.
GENERIC ED ONSET H/L(hrs) Alprazolam 1 Intermediate 6 -20 Lorazepam 2 Intermediate 10- 20 Triazolam 0.25-0.5 Intermediate 2-3 Clonazepam 0.5 Intermediate 18-50 Oxazepam 15-30 Slow 3-21 Temazepam 30 Intermediate 10-12 CDZ 25 Intermediate 5-200 Diazepam 10 Rapid 30-200
Withdrawal Withdrawal is influenced by: • Length of use. • Dose. • Half-life; shorter half-lives have more severe and faster onset of withdrawal. • Greater risk of withdrawal seizures in patients who also abuse alcohol. • Barbiturate withdrawal tends to be more severe and carries greater risk for seizure than BDZ withdrawal.
Physical Stiffness Weakness GI disturbance Paraesthesia Flu-like symptoms Visual disturbances Psychological Anxiety/insomnia Nightmares Depersonalization Decreased memory and concentration Delusions and hallucinations Depression Withdrawal Symptoms
Chronic user Patients should not be stopped abruptly-potential for dangerous withdrawal. There are two approaches to detoxification: • substitution • Gradual tapering
Substitution • Substitute long/IM-acting BDZ (clonazepam) or phenobarbital at equivalent dose. • Lorazepam is generally not considered - high abuse potential. • Split the equivalent dose over 3-4x daily dosing. • Can give additional doses for withdrawal symptoms first week only and then taper gradually.
Gradual tapering • Outpatient setting. • Dependent on therapeutic doses, • Decrease dose by 10% each week or decrease 50% within first few days, 25% over next week and then last 25% over several weeks. • Expect last 25% reduction with more withdrawal symptoms. • If withdrawal occurs, increase dose slightly until symptoms resolve, hold the taper until patient is stable then taper at slower rate.
OVER-DOSE • Slurred speech • Ataxia • incoordination • Stupor • respiratory depression • coma. In older adults; paradoxical agitated confusion / delirium
Cross-tolerance • BZ- Alcohol, • Higher doses for anesthesia /sedation. • Overlapping Withdrawal symptoms tachycardia, hypertension, agitation, anxiety, insomnia, tremor, nausea, diarrhea, and sensory disturbances. • Severe withdrawal - delirium, seizures and death.
