Benzodiazepines
|
Lorazepam (Ativan®),
diazepam (Valium®, temazepam [Restoril®]),
clonazepam (Rivotril®), oxazepam (Serax®), chlordiazepoxide (Librium®) |
|
|
Route |
·
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 ·
Onset 2-4 days after discontinuation, duration
weeks or months ·
Anxiety, panic attacks, insomnia, emotional lability ·
Neurological symptoms: dysperceptions,
depersonalization ·
Seizures, psychosis, delirium can occur with
abrupt cessation of doses equivalent to diazepam 50 mg per day or more |
|
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 |