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Benzodiazepine and Z-Drug Deprescribing Is a Benzodiazepine or Z-Drug still needed for sleep? August 2018 What are BenzodiazepineWhy is & patient Z-Drugs taking (BZRAs)? a BZRA? Stopping a BZRA is not for everyone Benzodiazepine receptor agonistsIf unsure, & Z-Drugs, find out or ifBZRAs, history areof anxiety, a class past of drugs psychiatrist consult,Some whetherpatients may may have need been to staystarted on in a hospitalBZRA for for a very specific reason. that are used to treat problemssleep, such oras for anxiety grief reaction. or difficulty sleeping. However, most need a BZRA for a short period of time. There are many different types of BZRA drugs: People who may need to continue on a BZRA include those with any of the • Insomnia on its own OR insomnia where underlying comorbidities managed following: • Other sleeping disorders (e.g. restless legs) •For Alprazolam those ≥ 65 (Xanax years® )of age: taking BZRA regardless• Lorazepam of duration (Ativan® (avoid) as first line therapy in older people) • • Unmanaged anxiety, depression,Unmanaged physical anxiety, or depression, mental condition physical that or may mental be •For Bromazepam those 18-64 (Lectopam years of age:®) taking BZRA •> 4Nitrazepam weeks (Mogadon®) condition that may be causing or aggravating insomnia causing or aggravating insomnia • Chlordiazepoxide (Librax®) • Oxazepam (Serax®) • Benzodiazepine effective specifically for anxiety • Clonazepam (Rivotril®) • Temazepam (Restoril®) • Anxiety that has been• specificallyAlcohol withdrawal and effectively managed with the BZRA ® (discuss potential risks, benefits,® withdrawal plan, symptoms and duration) •Engage Clorazepate patients(Tranxene ) • Triazolam (Halcion ) • Alcohol withdrawal • Diazepam (Valium®) • Zopiclone (Imovane®, Rhovane®) ® ® • Flurazepam (DalmaneRecommend) • Zolpidem Deprescribing (Sublinox ) How to safely reduceContinue a BZRA BZRA People between 18 and 64 years• Minimize of age who use haveof drugs been that taking worsen a BZRA for Why use less of, or stop using a BZRA? insomnia more than 4 weeks, andinsomnia people (e.g. 65 yearscaffeine, of agealcohol or older etc.) taking a • Treat underlying condition BZRAsTaper used andas sleeping then pills stop are usually BZRA only helpful for a short period BZRA for insomnia regardless of how long, should talk to their health care provider about whether stopping• Consider a BZRA consulting is the right psychologist choice for orthem. (around(taper slowly4 weeks) in collaboration of nightly withuse. patient, After afor few example weeks, ~25% the every brain two gets weeks, used and to if possible, 12.5% reductions near psychiatrist or sleep specialist theend effects and/or of planned the BZRA drug-free and itdays) may not work as well as it did at first, but can Doctors, nurse practitioners or pharmacists can help to decide on the best still causeFor those side effects.≥ 65 years of age (strong recommendation from systematic review andapproach GRADE approach) to using less of a BZRA. They can advise on how to reduce the dose, when to use drug-free days, and whether to stop the drug altogether. BZRAsFor can those cause 18-64dependence, years memory of age problems(weak recommendation and daytime from fatigue. systematic They review and GRADE approach) are also associated with dementia and falls (sometimes resulting in broken They can also give advice on how to make lifestyle changes that can bones).Offer The behavioural chance of experiencing sleeping these advice; effects consider may be CBThigher if asavailable people (see reverse)manage insomnia. get older. Many countries recommend against using BZRAs for sleep in Slowly reducing the doseIf symptoms of the BZRA relapse: helps to reduce the severity of older people. withdrawal effects. PeopleConsider are more successful in stopping their BZRA if theyUse slowly non-drug reduce the dose instead of just suddenly stopping it. Some Because BZRAs don’t work as well after a few weeks and because they can Maintaining current BZRA dose for 1-2 weeks, then Monitor every 1-2 weeks for duration of tapering approaches to people can reduce the dosecontinue over the to tapercourse at slowof a fewrate weeks; others need causeExpected side effects, benefits: it’s reasonable for many people, especially older people, manage to try and stop taking them and learn to fall asleep on their own again. several months. May improve alertness, cognition, daytime sedation and reduce falls insomnia Alternate drugs SwitchingUse behavioral from a short-actingOther BZRA medications to a long-acting have been one used has to beenmanage Withdrawal symptoms: recommendedapproaches in the past insomnia.but has not Assessment been shown of their to be safety more and effective than Insomnia, anxiety, irritability, sweating, gastrointestinal symptoms slowlyand/or lowering CBT the dose ofeffectiveness a short-acting is beyond drug. the scope of this algorithm. (all usually mild and last for days to a few weeks) (see reverse) See BZRA deprescribing guideline for details. © Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Contact [email protected] or visit deprescribing.org for more information. Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B (2016). Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. Can Fam Physician 2018;64:339-51 (Eng), e209-24 (Fr) Is a Benzodiazepine or Z-Drug still needed for sleep? August 2018 What to expect afterWhy reducing is patient a BZRA taking a BZRA? What to do if insomnia continues Some people may have difficultyIf unsure, sleeping find whenout if historya dose isof anxiety,first reduced, past psychiatrist but consult,Talk to whether a health may care have provider been started about in treating hospital underlying for conditions that many will not. Difficulty sleepingsleep, tends or for to griefbe worstreaction. in the first few days after are affecting sleep. Avoid using other medication to treat insomnia. Most reducing or stopping, and usually resolves in a few weeks. sedatives contribute to sedation and increase risk of falls. Ask about “cognitive behavioural therapy” – an educational approach that has Some• Insomnia people on have its own other OR symptomsinsomnia where of withdrawal underlying (e.g.comorbidities anxiety, irritability,managed • Other sleeping disorders (e.g. restless legs) been shown to help patients stop BZRA. Check out this resource for more andFor sweating); those ≥ 65 these years symptoms of age: taking tend BZRA to beregardless most severe of duration in the (avoid first asfew first days line therapy in older people) • Unmanaged anxiety, depression, physical or mental andFor get those better 18-64 within years a fewof age: weeks. taking If BZRAanything > 4 weeks odd happens, people should information: http://sleepwellns.ca/condition that. You may can be causingalso discuss or aggravating other options insomnia for talk to a health care provider for advice. managing your insomnia• Benzodiazepine if it gets worse effective when you specifically use a lower for anxiety dose or stop your BZRA. • Alcohol withdrawal ReducingEngage or stopping patients a BZRA may(discuss improve potential alertness risks, benefits, and thinking withdrawal ability, plan, symptoms and duration) and reduce daytime sedation and fall risk. Personalized BZRA dose reduction strategy: Other ways toRecommend manage insomnia Deprescribing _____________________________________________________________Continue BZRA Minimize use of drugs that worsen For a person who lives in the community: _____________________________________________________________• insomnia (e.g. caffeine, alcohol etc.) • Go to bed only when sleepy _____________________________________________________________• Treat underlying condition •Taper Do not use and bed or then bedroom stop for anything BZRA but sleep (or intimacy) • Consider consulting psychologist or •(taper If not slowly asleep in withincollaboration 20-30 withmin patient,on going/returning for example ~25% to bed, every exit two the weeks, bedroom and if possible, 12.5%_____________________________________________________________ reductions near psychiatrist or sleep specialist end and/or planned drug-free days) • Use alarm to awaken at the same time every morning _____________________________________________________________ • DoFor not those nap ≥ 65 years of age (strong recommendation from systematic review and GRADE approach) • Avoid caffeine after noon _____________________________________________________________ • AvoidFor exercise,those 18-64 nicotine, years alcohol, of andage big(weak meals recommendation 2 hours before from bedtime systematic review and GRADE approach) _____________________________________________________________ For a patientOffer behavioural who lives in long-term sleeping care advice; or hospital: consider CBT if available (see reverse) • Pull up curtains during the day for light exposure This pamphletIf symptoms accompanies relapse: a deprescribing guideline and • Keep alarm noises to a minimum algorithm thatConsider can be used by doctors, nurse practitioners, or • Increase daytime activity Use non-drug pharmacistsMaintaining to guide current deprescribing. BZRA dose for 1-2 weeks, then •Monitor Reduce number every of naps 1-2(no more weeks than 30 minutesfor duration and no naps after of 2pm)tapering
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