 |
Lorazepam (Ativan®), diazepam (Valium®, temazepam [Restoril®]), clonazepam (Rivotril®), oxazepam (Serax®), chlordiazepoxide (Librium®) |
| Routes |
| > Oral |
| Safe Limits |
| > No safe limits established > Women with psychiatric indication for benzodiazepine use may be maintained on therapeutic doses > Consider taper to lowest possible dose |
| Symptoms of Intoxication and Overdose |
| > Drowsiness, slurred speech, ataxia, disinhibition > Overdose: Coma and respiratory depression, especially if combined with alcohol, opiates, other sedatives > Treat symptomatically, manage airway > !! DO NOT USE FLUMAZENIL IN PHYSICALLY DEPENDENT PATIENTS (CAN TRIGGER SEIZURES, ARRHYTHMIAS) |
| Acute Adverse Effects |
| > Decreased respiratory drive > Rebound insomnia after 3 weeks use |
| Complications of Chronic Use |
| > Depression > Falls and confusion (more in elderly) |
| Withdrawal |
> Risk of withdrawal after two months of daily use; even at therapeutic doses |
| Benzodiazepine Tapering Protocol |
| Patient using >60-80 mg diazepam or equivalent per day: > Inpatient management preferred > Start at 2/3-3/4 of the diazepam equivalent dose > Taper by no more than 10% per day > Adjust dose and rate of taper according to symptoms Patient using <60 mg diazepam per day, not double-doctoring: > Slow outpatient taper > Taper by 5 mg diazepam equivalent q 1-2 weeks > Taper with benzo they are on or switch to clonazepam or diazepam (longer half-life) > Weekly or daily dispensing > Scheduled doses, supportive counselling > May need to slow taper near end |
| Teratogenicity |
| > Some but not all studies found a slight increase in risk of cleft lip and/or palate with first trimester benzodiazepine use; avoid if possible > Consider Level 2 ultrasound in second trimester to rule out facial anomalies |
| Obstetrical Complications |
| > Sedates fetus (flat tracing, depressed fetal behaviour) |
| Management of Neonate |
| > Heavy use during or just prior to labour can result in "floppy baby syndrome" (hypotonic muscles, lethargy, respiratory problems, hypothermia and sucking difficulties) > Neonatal withdrawal reported: abnormal sleep patterns, tremors, hyperreflexia, irritability, hypertonia, diarrhea, vomiting, apnea and vigorous sucking > Treatment: observation and routine care |
| Breastfeeding |
| > Chronic benzodiazepine use in nursing mothers has been reported to cause infant lethargy and weight loss; monitor closely |
