Benzodiazepines learning module

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Question 1

Phil was recently burgled in his digs. He has become anxious and has been lying awake for much of the night. A 5-day supply of a benzodiazepine hypnotic has been prescribed to help him cope with the insomnia. Which of the following pieces of advice would be appropriate for Phil:

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  • Take this medicine for 3–4 days to establish sleep pattern and then stop
  • You must not share this medicine with anybody else and you should store it in a safe place
  • Make sure you read the leaflet that accompanies your medicine, especially the section on how to take your medicine
  • You must complete the course prescribed for you
  • It is alright to drink alcohol socially with this medicine

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  • If i, ii and iii are correct


    Correct

    i. Take this medicine for 3–4 days to establish sleep pattern and then stop

    Long-term use of a benzodiazepine for insomnia must be avoided. Benzodiazepine dose for 3–4 days may be sufficient to re-establish a sleep pattern.

    ii. You must not share this medicine with anybody else and you should store it in a safe place

    There is considerable potential for diversion of benzodiazepines—ending up being used for illicit or recreational purposes. Phil should take responsibility for safe use and secure storage of the medicine.

    iii. Make sure you read the leaflet that accompanies your medicine, especially the section on how to take your medicine

    The patient information leaflet reinforces the advice on how to take the medicine and the warnings about avoiding prolonged use and concomitant use of alcohol.


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    iv. You must complete the course prescribed for you

    The benzodiazepine should be stopped as soon as normal sleep pattern is established (usually about 3–4 days) and further doses should not be taken even if some of the medicine remains unused. Phil should be advised to return all unwanted medicines promptly to a pharmacy for safe disposal.

    v. It is alright to drink alcohol socially with this medicine

    Alcohol should not be taken while on benzodiazepine treatment. Benzodiazepines and alcohol both depress the CNS—the combination may increase sedation and depress cardiovascular and respiratory function. Alcohol consumption during ‘social drinking’ can vary considerably and present a potential for dangerous effects when a benzodiazepine is also taken.

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  • If ii and iv are correct


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  • If only v is correct


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  • If i, ii, iii and v are correct


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  • If all are correct


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Question 2

Which of the following statements about benzodiazepine withdrawal effects is true?

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Question 3

Ali has been taking lorazepam 7.5 mg daily (generally 2.5 mg twice during the day and 2.5 mg at bedtime) for the last 9 months. Ali says that the ‘pills don’t seem to be doing any good but I just can’t seem to cut them out’. Which of the following seem the best options for moving forwards:

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  • Ask Ali to try harder (and ‘work through the pain’) to cut out the benzodiazepines
  • Agree a withdrawal plan with Ali involving a switch to diazepam
  • Ask Ali to cut out the middle dose and just continue on lorazepam 2.5 mg midmorning and 2.5 mg at bedtime
  • Give Ali a leaflet on benzodiazepine withdrawal and involve the family in supporting Ali through the withdrawal effects
  • Substitute the benzodiazepine for another class of anxiolytics

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  • If i, ii and iii are correct


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  • If ii and iv are correct


     


    Correct

    ii. Agree a withdrawal plan with Ali involving a switch to diazepam

    The management of withdrawal can be difficult and it is best attempted by switching to a longer-acting benzodiazepine such as diazepam, with a gradual dose reduction to avoid serious withdrawal effects such as convulsions or acute psychosis.

    iv. Give Ali a leaflet on benzodiazepine withdrawal and involve the family in supporting Ali through the withdrawal effects

    An information sheet on withdrawal can be effective in encouraging reduction or cessation of benzodiazepine use. The management of withdrawal can be difficult and is best attempted in the context of support from family and health professionals, and with access to psychological therapy. Withdrawal may need to be conducted in a specialist centre for particularly difficult cases such as long-term dependence on a high-dose or multiple-substance abuse.


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    i. Ask Ali to try harder (and ‘work through the pain’) to cut out the benzodiazepines

    It is important to understand Ali’s challenge. The best way forward would be to discuss a mutually agreed plan for withdrawing the benzodiazepines as it is more likely to be effective through better education and commitment from the patient. It is more difficult to manage withdrawal in an individual on a short-acting or intermediate-acting benzodiazepine such as lorazepam.

    iii. Ask Ali to cut out the middle dose and just continue on lorazepam 2.5 mg midmorning and 2.5 mg at bedtime

    Dose reduction needs to gradual (reduced by around one-eighth of the daily dose each fortnight) to avoid serious withdrawal effects such as convulsions and psychosis. The benzodiazepine first needs to be switched to the equivalent dose of a longer-acting one such as diazepam.

    v. Substitute the benzodiazepine for another class of anxiolytics

    The benzodiazepine should not be replaced with another class of anxiolytic, which may also cause dependence and withdrawal reactions. Benzodiazepine dose reduction needs to be gradual to avoid serious withdrawal effects. Switching to an equivalent dose of a longer-acting benzodiazepine such as diazepam allows smoother dose reduction.

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  • If i, ii, iii and v are correct


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  • If all are correct


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Question 4

Which of the following statements are true?

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  • A benzodiazepine usually impairs recall of events that occurred before starting benzodiazepine treatment
  • With prolonged use of a benzodiazepine, the effects on memory are reversed as the sedative effect wears off
  • A CNS stimulant can reverse benzodiazepine-induced memory loss
  • Memory is repaired within about a fortnight of discontinuing a prolonged course of a benzodiazepine
  • A single dose of a benzodiazepine can interfere with recall of events that happen while clinically significant amount remains in the body

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  • If only v is correct


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    v. A single dose of a benzodiazepine can interfere with recall of events that happen while clinically significant amount remains in the body

    Benzodiazepines can induce sedation and anterograde amnesia ie loss of memory of events occurring after the first dose is taken. This effect is of benefit in surgery and when faced with unpleasant medical procedures.


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    i. A benzodiazepine usually impairs recall of events that occurred before starting benzodiazepine treatment

    Benzodiazepines can induce sedation and anterograde amnesia ie events occurring after the first dose is taken, not retrograde effects.

    ii. With prolonged use of a benzodiazepine, the effects on memory are reversed as the sedative effect wears off

    Benzodiazepines seem to have specific amnesic effects and memory impairment cannot be fully explained by the sedative effects. Over time, tolerance develops to benzodiazepine sedative effects but memory impairment may persist even after discontinuation.

    iii. A CNS stimulant can reverse benzodiazepine-induced memory loss

    There is no specific treatment to reverse benzodiazepine-induced memory loss. The benzodiazepine should be stopped as soon as possible, but memory may be impaired for a long time after discontinuation.

    iv. Memory is repaired within about a fortnight of discontinuing a prolonged course of a benzodiazepine

    Memory impairment may persist for months or years after discontinuation.

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Question 5

Sophie takes clonazepam for epilepsy. She has rushed into the late clinic very concerned that her 7-year-old son Louis swallowed the last 2-mg clonazepam tablet from the blister pack soon after he got back from school around 3:30 pm. Louis had his meal before Sophie noticed that the tablet was missing. It’s now 7:30 pm. Louis is quiet and a little sleepy. His colour is good and his blood pressure, pulse and respiratory rate are unremarkable. What do you do? Choose the single best answer

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Question 6

Which of the following can increase the risk of adverse respiratory effects of benzodiazepines?

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  • Chronic obstructive pulmonary disease
  • Sleep apnoea
  • Fentanyl transdermal patches
  • Nicotine transdermal patches
  • Beta-lactam allergy

Choose your answers as follows:

  • If i, ii and iii are correct


    Correct


    i. Chronic obstructive pulmonary disease

    Factors that increase the risk of respiratory adverse effects include respiratory disease, CNS depression from another cause, coma, neuromuscular disorders such as myasthenia gravis, sleep apnoea syndrome, and co-administration of a benzodiazepine with another CNS depressant such as opioid analgesics.

    ii. Sleep apnoea

    Factors that increase the risk of respiratory adverse effects include respiratory disease, CNS depression from another cause, coma, neuromuscular disorders such as myasthenia gravis, sleep apnoea syndrome, and co-administration of a benzodiazepine with another CNS depressant such as opioid analgesics.

    iii. Fentanyl transdermal patches

    Fentanyl is a potent opioid. Factors that increase the risk of respiratory adverse effects include respiratory disease, CNS depression from another cause, coma, neuromuscular disorders such as myasthenia gravis, sleep apnoea syndrome, and co-administration of a benzodiazepine with another CNS depressant such as opioid analgesics.


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    iv. Nicotine transdermal patches

    Nicotine does not generally have a sedative effect nor does it affect respiratory function. It does not have a potential for interaction with benzodiazepines. Factors that increase the risk of respiratory adverse effects include respiratory disease, CNS depression from another cause, coma, neuromuscular disorders such as myasthenia gravis, sleep apnoea syndrome, and co-administration of a benzodiazepine with another CNS depressant such as opioid analgesics.

    v. Beta-lactam allergy

    Beta-lactam allergy should not cause adverse respiratory effects of benzodiazepines. There is no cross-sensitivity between beta-lactams and benzodiazepines. Factors that increase the risk of respiratory adverse effects include respiratory disease, CNS depression from another cause, coma, neuromuscular disorders such as myasthenia gravis, sleep apnoea syndrome, and co-administration of a benzodiazepine with another CNS depressant such as opioid analgesics.

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  • If ii and iv are correct


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  • If only v is correct


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  • If i, ii, iii and v are correct


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  • If all are correct


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Question 7

Which of the following statements is correct?

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Question 8

Which of the following circumstances represents appropriate use of a benzodiazepine?

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Question 9

Lizzie, a 58-year-old married woman was recently knocked off her bike and sustained a compound fracture to her arm. She takes up to 8 tablets of co-codamol 15/500 daily (in 4 divided doses). Lizzie was prescribed a 2-week course of a benzodiazepine hypnotic to help her sleep at night. However, she now says that she is having awful nightmares and has outbursts over quite trivial matters. What is the best course of action? (Select the single best answer.)

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  • Switch Lizzie’s analgesic to a NSAID so she is not taking an opioid


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    The opioid in the analgesic tablets and the hypnotic can interact, but the interaction is likely to result in CNS depression rather than the symptoms Lizzie reports. Nightmares and outbursts after starting the hypnotic could be due to ‘paradoxical’ effects of benzodiazepines. Though paradoxical effects are rare, children and the elderly are more prone to them as are those with a history of alcohol abuse or of psychiatric disorder, and those taking a high dose.

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  • Increase the dose of the hypnotic


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    Increasing the dose could cause further difficulty since nightmares and outbursts after starting the hypnotic could be due to ‘paradoxical’ effects of benzodiazepines. Though paradoxical effects are rare, children and the elderly are more prone to them as are those with a history of alcohol abuse or of psychiatric disorder, and those taking a high dose.

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  • Refer Lizzie to a neurologist in case she has sustained a head injury that was not picked up previously


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    While complications following head injury cannot be fully ruled out, nightmares and outbursts after starting the hypnotic could be due to ‘paradoxical’ effects of benzodiazepines. Though paradoxical effects are rare, children and the elderly are more prone to them as are those with a history of alcohol abuse or of psychiatric disorder, and those taking a high dose.

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  • Consider discontinuing the benzodiazepine hypnotic


    Correct

    Nightmares and outbursts after starting the hypnotic could be due to ‘paradoxical’ effects of benzodiazepines. Though paradoxical effects are rare, children and the elderly are more prone to them as are those with a history of alcohol abuse or of psychiatric disorder, and those taking a high dose.

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  • Reassure Lizzie that these effects are probably due to the trauma and will pass in time


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    Lizzie’s report of these effects, which occurred after starting the hypnotic, should lead to the discontinuation of the benzodiazepine because their use is occasionally associated with ‘paradoxical’ effects which include aggression with rages and nightmares.

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Question 10

Which of the following sets of effects are associated with the long-term use of a benzodiazepine:

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  • Depression, disinhibition, osteoporosis, pathological gambling


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    Depression and disinhibition are recognised long-term effects of benzodiazepines but osteoporosis and pathological gambling are not characteristic effects.

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  • Forgetfulness, hypotension, muscle weakness, parkinsonism


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    Amnesia is a recognised long-term effect of benzodiazepines and muscle relaxation and muscle weakness, which occur on short-term use, may also be present with continued use. However, parkinsonism is not a characteristic benzodiazepines effect. Though benzodiazepines have the potential for reducing blood pressure, clinically significant hypotension is unlikely.

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  • Depression, ‘emotional anaesthesia’, forgetfulness, inability to concentrate


    Correct

    Depression (which, when accompanied by disinhibition, can lead to suicidality), blunting of emotions, amnesia, and poor concentration are all characteristic long-term adverse effects of benzodiazepines.

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  • Constipation, glaucoma, tardive dyskinesia, tolerance


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    Tolerance develops to the various effects of benzodiazepines. However, constipation, glaucoma and tardive dyskinesia are not characteristic effects of benzodiazepines.

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  • Ataxia, convulsions, depression, ECG changes


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    Ataxia can occur early during benzodiazepine use, but psychomotor impairment can also be a feature of long-term use, as is depression. Convulsions can occur on sudden withdrawal of a benzodiazepine. ECG changes are not characteristic benzodiazepine effects.

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Question 11

Susie, an 82-year-old lady, has been in hospital receiving treatment for community-acquired pneumonia. In hospital, three days before she was discharged, Susie was put on temazepam 10 mg at bedtime to help her sleep in the busy acute ward. On discharge, she brought home a 5-day supply of temazepam, together with some antibiotics. When you see her on the first day back, she is ‘feeling miles better’ except for ‘wooziness’ in the mornings over the last day or two. Beyond encouraging Susie to complete the course of antibiotics, how would you continue her care?

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Question 12

Which of the following statements is correct about benzodiazepine-related withdrawal symptoms?

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Page last modified: 17 February 2015