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Clinician’s Corner: Anxiety and Benzodiazepines

Anxiety is a part of normal live and today everyone seems stressed out.  When stress becomes unbearable many turn to their physician for help.  Physicians do prescribe drugs from the benzodiazepine class with a great deal of caution, given the significant adverse effects.

Stress, fear and anxiety are interactive. Two components of anxiety are:

  • Psychological: tension, fears, difficulty in concentration, apprehension
  • Somatic: heart palpitations, excessive sweating, tremor, GI disturbances, fatigue and sleep disturbances

MOST COMMONLY AVAILABLE BENZODIAZEPINES

DRUG NAME YEAR of Approval USUAL Daily Dose Maximum Daily Dose EQUIV Daily Dose Half Life
Alprazolam (Xanax®) 1981 0.5-1.5mg 4mg 0.5mg 6-27hrs
Chlordiazepoxide (Librium®) 1960 10-20mg 100mg 10mg 5-30hrs
Clonazepam (Klonopin®) 1975 1-2mg 10mg 0.25mg 18-50hrs
Diazepam (Valium®) 1963 5-15mg 30mg 5mg 20-50hrs
Lorazepam (Ativan®) 1977 2-4mg 4mg 1mg 10-20hrs
Oxazepam (Serax®) 1965 10-30mg 60mg 15mg 5-20hrs

* EQUIV= approximate equivalent daily dosages (for comparison)

PRESCRIBING NOTES

** the above doses are total daily doses divided into 2 to 4 portions per day.

** shorter acting benzos are more likely to be abused (overused)

**avoid combining with opioids due to overdose risk of opioids

**distinctive feature of the benzodiazepines is the wide margin of safety, between therapeutic and toxic doses.

**Ataxia, and sedation occur at doses beyond those needed for anxiolytic effects.

**all benzodiazepines are in Schedule IV.  Maximum 5 refills.  Rx good for 6 months Max.

** Drugs safest for elderly due to minimal liver metabolism: Lorazepam, Oxazepam, Temazepam

Adverse Reactions (General adverse reactions of Benzodiazepines)

NERVOUS SYSTEM:  sedation and sleepiness, depression, lethargy, apathy, fatigue, hypoactivity, lightheadedness, memory impairment, disorientation, amnesia, restlessness, confusion, delirium, headache, slurred speech, stupor, coma, syncope, euphoria, irritability, difficulty in concentration, agitation, vivid dreams, psychomotor retardation

SKIN:  hives, hair loss, ankle and facial edema

GI:  constipation, dry mouth, coated tongue, sore gums, change in appetite

Genito Urinary:  change in sex drive, urinary retention

EYES: double vision, nystagmus

PSYCH: behavioral problems, hysteria, suicidal tendencies

MISC: sweating, gynecomastia, may elevate liver enzymes, hepatic dysfunction, anemias

Patient information:

  • May cause drowsiness: avoid driving or other tasks requiring alertness
  • Avoid alcohol or other CNS depressants
  • May take with food or water if stomach upset occurs.

Withdrawal concerns:

Relapse or rebound of condition being treated

Withdrawal symptoms: sweating, fast heartbeat, tremor, insomnia, anxiety, agitation, nausea, vomiting, hallucinations, and seizures.

Overdose when combined with opioids:

More than 30 percent of overdoses involving opioids also involve benzodiazepines

In 2016, the Centers for Disease Control and Prevention (CDC) issued new guidelines for the prescribing of opioids. They recommend that clinicians avoid prescribing benzodiazepines concurrently with opioids whenever possible. Both prescription opioids and benzodiazepines now carry FDA “black box” warnings on the label highlighting the dangers of using these drugs together.

Lethal due to enhanced sedation and suppressed breathing.

Tapering doses of Benzodiazepines:

Patients on high doses, or long-term therapy may experience withdrawal symptoms on abrupt cessation of therapy.  Do not discontinue therapy abruptly or change dosage except on advice of health care practitioner.

Rationale for Taper:

Relapse or rebound of condition being treated; withdrawal symptoms: sweating, tachycardia, tremor, insomnia, anxiety, agitation, nausea, vomiting, hallucinations, and seizures.

Risk factors: use over one-year, high dose, short or intermediate half-life such as  Xanax ® (alprazolam); (especially if daily dose >4 mg for >12 weeks), Ativan®  (Lorazepam).

Suggested taper: methods:

Clonazepam switch and taper: for withdrawal from shorter acting benzodiazepines substitution of a longer acting (example: 1mg of Clonazepam for each 1-2mg of Alprazolam or Lorazepam) may provide more sustained anxiolytic effects to facilitate gradual withdrawal.

Your Thompson Pharmacist is a great resource for your mental health needs. Whether starting drug therapy or tapering off long term benzodiazepines your Thompson Pharmacist is here to help you deal with your medication concerns. Go Ahead and ASK…at Thompson Pharmacy it’s All for YOU!!