Guidelines for the rational use of benzodiazepines.
When and what to
use
by
Ashton H
Department of Psychiatry,
Royal Victoria Infirmary,
Newcastle upon Tyne,
England.
Drugs 1994 Jul; 48(1):25-40
ABSTRACT
The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant,
myorelaxant and amnesic) confer a therapeutic value in a wide range of
conditions. Rational use requires consideration of the large differences in
potency and elimination rates between different benzodiazepines, as well as the
requirements of individual patients. As hypnotics, benzodiazepines are mainly
indicated for transient or short term insomnia, for which prescriptions should
if possible be limited to a few days, occasional or intermittent use, or courses
not exceeding 2 weeks. Temazepam, loprazolam and lormetazepam, which have a
medium duration of action are suitable. Diazepam is also effective in single or
intermittent dosage. Potent, short-acting benzodiazepines such as triazolam
appear to carry greater risks of adverse effects. As anxiolytics,
benzodiazepines should generally be used in conjunction with other measures
(psychological treatments, antidepressants, other drugs) although such measures
have a slower onset of action. Indications for benzodiazepines include acute
stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as
initial treatment for severe panic and agoraphobia. Diazepam is usually the drug
of choice, given in single doses, very short (1 to 7 days) or short (2 to 4
weeks) courses, and only rarely for longer term treatment. Alprazolam has been
widely used, particularly in the US, but is not recommended in the UK,
especially for long term use. Benzodiazepines also have uses in epilepsy
(diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders
and occasionally in acute psychoses. The major clinical advantages of
benzodiazepines are high efficacy, rapid onset of action and low toxicity.
Adverse effects include psychomotor impairment, especially in the elderly, and
occasionally paradoxical excitement. With long term use, tolerance, dependence
and withdrawal effects can become major disadvantages. Unwanted effects can
largely be prevented by keeping dosages minimal and courses short (ideally 4
weeks maximum), and by careful patient selection. Long term prescription is
occasionally required for certain patients.
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