By Sunjeev Uthayakumar, Stephanie Lau, Andrew Tu, and Certina Ho
What are Benzodiazepines?
Benzodiazepines are often listed as one of the most prescribed or dispensed drug classes. In 2016, a special report on top drugs of 2015 showed that some of the agents in this drug class are among the top 50 prescription drugs. The approved indications of benzodiazepines range from anxiety, panic disorder, insomnia, to sedation (e.g., in surgical procedures and ventilation), seizures, and alcohol withdrawal, etc., depending on the individual drug’s pharmacokinetic property and available clinical evidence.
(*Note: This is not a comprehensive list of benzodiazepines and their associated indications.)
Benefits and Risks of Benzodiazepines
The use of benzodiazepines should be individualized, closely monitored, and regularly evaluated with the patient. While benzodiazepines are helpful for managing medical conditions mentioned above, they are also associated with adverse effects, such as dizziness, drowsiness, and fatigue, etc. Long-term use of benzodiazepines (or short-term use of high doses) may lead to tolerance and/or dependence. On the other hand, abrupt withdrawal may lead to symptoms of anxiety, insomnia, gastrointestinal upset, hand tremor, increased heart rate, or other more severe symptoms (e.g., confusion, hallucinations, seizures, etc.).
It is important to note that patient’s medical conditions may change over time and the need for these medications (for example, as the patients age) may not be the same. Therefore, ongoing monitoring and re-assessment of the use of benzodiazepines should be discussed between the clinician (i.e., the care provider) and the patient. Weighing between the benefits and risks associated with the use (particularly, long-term use) of benzodiazepines and the discussion of alternative therapeutic options (or non-therapeutic interventions, where applicable), and opportunities for tapering or deprescribing should be considered.
Benzodiazepine Use in Older Adults
Since older adults are more sensitive to benzodiazepines and have decreased metabolism of the long-acting agents (Table 1) of this drug class, some of the adverse effects (mentioned above) may lead to an increased risk of falls, hip fractures, and/or motor vehicle accidents. The American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults (https://pubmed.ncbi.nlm.nih.gov/30693946/) listed benzodiazepines as medications that are potentially inappropriate in most older adults. The Beers Criteria® are intended for use in older adults, that is, patients 65 years of age and older (in most clinical care settings, with the exception of hospice and palliative care). It is updated every three years by the AGS and consists of a list of PIMs that should be best avoided by older adults in most circumstances or under specific medical conditions.
In addition, Choosing Wisely Canada recommends “Five Things Physicians and Patients Should Question” regarding geriatric patient care and one of them is: “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.”
On the other hand, the Mayo Clinic Proceedings provided a 2016 Concise Review for Clinicians on “Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies” , which included a summary of benzodiazepine use in older adults, associated risks of prescribing them, and evidence-based benzodiazepine-tapering protocols, etc. Physicians, nurse practitioners, and pharmacists can also reach out to GeriMedRisk , an interdisciplinary telemedicine consultation and education service for clinicians in Ontario, to learn more about safe and optimal medication use in older adults, and access to GeriMedRisk drug information, virtual rounds, and publications.
Deprescribing of Benzodiazepines
Initiating, continuing, and discontinuing the use of benzodiazepines should be a three-way partnership or mutual discussion and understanding among the older adults/patients, their caregivers, and their care providers (or clinicians), so that all parties are aware and informed of the potential benefits and risks of medication use. At the same time, non-pharmacologic interventions should also be considered, where applicable to the medical condition(s) involved.
Patients and their care givers can use the “5 Questions to Ask About Your Medications” to initiate a dialogue with their health care provider(s) to learn more about the medications that are prescribed and dispensed to them.
Clinicians and healthcare professionals may consult the deprescribing guidelines and algorithms (and other associated resources) available at www.deprescribing.org for further information, if there are medications that have been identified as potential candidates for deprescribing after a comprehensive medication review is conducted with the patient and/or the care giver. Readers are also invited to view a previous article in the Safe Medication column that was published in the August 2020 edition of Hospital News on “Deprescribing: When Less is More”.
Sunjeev Uthayakumar, Stephanie Lau, and Andrew Tu are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.