Benzodiazepines Flashcards
(13 cards)
What is the main thing to remember about benzos?
- give the lowest dose for the shortest time - to prevent tolerance and dependence
- Long acting/intermediate/short acting
- withdraw slowly (over weeks/months)
- do not use for mild symptoms
Benzodiazepines as anxiolytics
- Benzodiazepines are effective in alleviating anxiety states
- they are not appropriate for use in stress, unhappiness or minor physical disease
- benzodiazepines can inhibit psychological adjustment and bereavement
- Dependence particularly likely in patients with history of alcohol or drug abuse and with marked personality disorder
- limit treatment to lowest possible dose for shortest period of time
- Beta blockers do not affect psychological symptoms of anxiety, worry, fear,tension - but do reduce autonomic symptoms eg. Palpitations and tremor. Indicated in patients with predominantly somatic symptoms
Examples of Benzos
- Alprazolam (Short acting and intermediate)
- Diazepam(LA)
-Lorazepam (IM)
-Lormetazepam(SA)
-Loprazolam(SA)
-Oxazepam(SA)
-Chloridiazepoxide(LA)
-Temazepam(SA)
-Nitrazepam(LA)
-Clobazam(LA)
-Midazolam (SA)
Dependence and withdrawal
-withdrawal should be gradual
- Abrupt withdrawal may produce confusion,toxic psychosis,convulsion or a condition resembling delirium tremors (like alcohol withdrawal)
- Benzodiazepines withdrawal syndrome - is characterised by insomnia, anxiety,loss of appetite and body weight.tremors,perspiration,tinnitus and perceptual disturbance.
Some of these symptoms continue for weeks or months after discontinuing BDZ.
- BDZ withdrawal syndrome may develop at anytime up to 3 weeks after stopping a long acting benzo, but may occur within a day with SA acting ones.
- Some of these symptoms continue for weeks or months after stopping benzos
Duration of benzo withdrawal?
-Should be flexible and carried out over a reduction rate that us tolerable for the patient
- Rate should depend on initial dose, duration or use and the patients clinical response
- Short term uses (2-4 weeks only) can taper off within 2-4 weeks
- Long term users withdraw slowly over several months or more
Protocol for withdrawal
- transfer patients to an equivalent dose of diazepam (preferable at night)
- Reduce the does of diazepam by 1-2mg every 2-4 weeks. If withdrawal symptoms occur maintain a dose until symptoms unseen
- Reduce diazepam further if necessary in smaller steps of 500mcg towards the end of withdrawal. Then stop completely.
- For patients in long term use, withdrawal may take several months to a year or more
- withdrawal symptoms for long term users usually resolve within 6-18 months
Uses
- mainly sued for short term anxiety (2-4 weeks only) which is severe, disabling or causing the patient unacceptable distress, occurring alone or with insomnia or psychotic illness
- the use of benzodiazepines to treat ‘Mild” anxiety is inappropriate
- Avoid prescribing for stress related problems or unhappiness
Psychological adjustment may be inhibited by benzodiazepines - benzodiazepines should be used to treat insomnia only when it is severe,disabling or causing extreme distress
- other uses of benzodiazepines - muscle spasms, epilepsy, insomnia and alcohol withdrawal
- short acting benzodiazepines are preferred in patients with hepatic impairment and elderly but carry greater risk of withdrawal symptoms
- IV diazepam and IV lorazepam are occasionally used for panic attacks
Cautions with benzos
- avoid prolonged use
- avoid abrupt withdrawal
- patients with history of drug dependence and alcohol dependence
- paradoxical effects - opposite effects, opposite of what we were trying to give it for
(Increase in hostility and aggression, effects range from talativeness and excitement to aggression and antisocial actions) increased anxiety and perceptual disorders. - immediate adjustment of dose needed either up or down
Side effects of benzos
-decrease alertness
- anxiety
-ataxia
-confusion - more in the elderly
- dizziness and drowsiness
- fatigue
-Gi disorders
Weakness
-hypotension
-suicidal thought
Contraindications
-Acute pulmonary insufficiency
- unstable myasthenia gravies
- sleep apnoea syndrome - breathing interrupted during sleep
Can we give in pregnancy and breastfeeding
Avoid, but if pt is agitated - may want to use
- risk of neonatal withdrawal symptoms when used during pregnancy
- avoid regular use and use only if there is a clear indication eg. Seizure control
- high doses during pregnancy or labour may cause neonatal hypothermia,hypotonia(decreased muscle tone) and respiratory depression
- BDZ are present in breast milk and should be avoided if possible during breast feeding
Benzos patient and carer advice:
- drowsiness may persist the next day and affect performance of skilled tasks eg. Driving
- effects are enhanced by alcohol
Hepatic impairment
- can precipitate coma
- if treatment necessary then benzos with shorter half lives ( Lormetazepam,loprazolam,temazepam and oxazepam,midazolam and alprozolam (LLATOM)
Avoid in sever impairment - but shorter half lives are considered safer
