Are benzodiazepines (BZDs) contraindicated in multiple sclerosis (MS)?

Benzodiazepines in Multiple Sclerosis: Safety and Considerations

Benzodiazepines are not contraindicated in multiple sclerosis (MS), but should be used with caution due to their potential adverse effects on mobility, cognitive function, and risk of falls, which may exacerbate existing MS symptoms. 1

Current Usage Patterns in MS

Benzodiazepines are commonly prescribed in the MS population:

• Recent research shows that 16.23% of MS patients receive anxiolytic prescriptions 2
• MS patients have a 39% increased incidence rate of benzodiazepine use compared to the general population 3
• MS patients are more likely to use benzodiazepines chronically (≥6 months) than people without MS 3

Benefits in MS

Benzodiazepines may provide some benefits in MS patients:

• They can help manage anxiety, which is common in MS patients 2
• They may be used for muscle spasticity management, though not as first-line therapy 4
• Some experimental evidence suggests potential immunomodulatory effects, as alprazolam has shown beneficial effects in an experimental autoimmune encephalomyelitis model 5

Risks and Concerns

The primary concerns with benzodiazepine use in MS patients include:

1. Exacerbation of MS-related symptoms:

   • May worsen cognitive impairment, which is already common in MS 1
   • Can reduce mobility and functional independence 1
   • May increase risk of falls and fractures 1

2. Dependency and tolerance:

   • MS patients show higher rates of chronic benzodiazepine use 3
   • Case reports document severe dependency in MS patients 4

3. Polypharmacy concerns:

   • MS patients often take multiple medications, increasing the risk of drug interactions 6

Recommendations for Use

When benzodiazepines are considered necessary in MS patients:

1. Short-term use only:

   • Current consensus guidelines advise benzodiazepines solely on a short-term basis 1
   • Avoid long-term prescriptions due to increased risk of dependency

2. Consider alternatives first:

   • For pain management: acetaminophen is safer than benzodiazepines 1
   • For muscle spasticity: consider gabapentin or pregabalin as preferred options 1
   • For anxiety: SSRIs or SNRIs may be more appropriate for long-term management 7

3. If prescribing is necessary:

   • Use the lowest effective dose 7
   • Monitor closely for cognitive effects, mobility changes, and fall risk
   • Have a clear tapering plan from the beginning 7
   • Educate patients about risks and benefits 7

Tapering Considerations

If an MS patient is already on benzodiazepines and discontinuation is desired:

• Implement a gradual tapering schedule (25% reduction every 1-2 weeks) 7
• Monitor for withdrawal symptoms and adjust the taper rate accordingly 7
• Consider cognitive behavioral therapy to support the tapering process 7
• Be alert for emergence or worsening of anxiety, depression, or MS symptoms during the taper 7

Special Considerations in MS

• Respiratory concerns: MS patients with bulbar involvement may be at higher risk for respiratory depression 1
• Cognitive impact: MS patients already experiencing cognitive symptoms may be more vulnerable to benzodiazepine-related cognitive impairment 1
• Fall risk: MS patients with gait or balance issues face compounded fall risk with benzodiazepine use 1

In conclusion, while benzodiazepines are not absolutely contraindicated in MS, their use should be limited to short-term therapy when other safer alternatives have failed, with careful monitoring for adverse effects that could worsen MS-related disability.