What are safe sedatives for a 78-year-old patient with multiple myeloma?

Safe Sedatives for a 78-Year-Old Patient with Multiple Myeloma

Midazolam is the first-line benzodiazepine for sedation in elderly multiple myeloma patients, with lorazepam as an alternative when oral administration is preferred. 1, 2

First-Line Sedative Options

• Midazolam: Recommended as first-line benzodiazepine for anxiety, agitation, and palliative sedation in cancer patients, including those with multiple myeloma 1, 2

  • Starting dose: 0.5-1 mg/hour continuous infusion or 1-5 mg as needed
  • Advantages: Rapid onset, can be administered intravenously or subcutaneously, can be co-administered with morphine or haloperidol 1
  • Caution: Monitor for respiratory depression, especially in elderly patients 1

• Lorazepam: Alternative benzodiazepine option when oral administration is preferred 2, 3

  • Lower doses should be sufficient for elderly patients (start with lowest effective dose) 3
  • Caution: Greater sensitivity to sedation and unsteadiness has been observed in elderly patients 3

Second-Line Options

• Levomepromazine (Methotrimeprazine): Useful when patients exhibit signs of delirium 1

  • Starting dose: 12.5-25 mg
  • Advantages: Rapid onset, antipsychotic effect, some analgesic effect 1
  • Caution: Monitor for orthostatic hypotension, which can be particularly problematic in elderly patients 1

• Chlorpromazine: Alternative antipsychotic for delirious patients 1

  • Starting dose: 12.5 mg every 4-12 hours (intravenous or intramuscular)
  • Caution: Monitor for orthostatic hypotension and anticholinergic effects 1

Special Considerations for Multiple Myeloma Patients

• Avoid benzodiazepines for long-term use: Studies show that benzodiazepines are among the most common potentially inappropriate medications in elderly multiple myeloma patients 4

  • 8% of elderly multiple myeloma patients were found to be using potentially inappropriate benzodiazepines 4
  • Benzodiazepine use during autologous stem cell transplantation often persists long-term 5

• Pain management considerations: Multiple myeloma patients often require pain management alongside sedation 1

  • For mild pain: Paracetamol up to 1g four times daily 1
  • For moderate to severe pain: Consider opioids like fentanyl, buprenorphine patches, or oxycodone 1
  • Avoid NSAIDs in multiple myeloma patients due to potential renal complications 1

Monitoring and Precautions

• Respiratory monitoring: Closely monitor respiratory function, especially when combining sedatives with opioids 1

• Dose adjustments: Start with lower doses in elderly patients and those with renal impairment, which is common in multiple myeloma 1, 3

• Short-term use: Plan for short-term rather than chronic use of sedatives 4

• Delirium assessment: Differentiate between anxiety and delirium before administering benzodiazepines, as they can worsen delirium 2

• Frailty evaluation: Consider frailty status when selecting sedatives, as frailty is prevalent in elderly multiple myeloma patients and affects treatment outcomes 6

Non-Benzodiazepine Options

• Eszopiclone: May be considered for insomnia in elderly patients 7

  • Lower doses (1-2 mg) are recommended for elderly patients 7
  • Caution: Monitor for next-morning impairment, confusion, and memory issues 7

• Zolpidem: Alternative for short-term insomnia management 8

  • Recommended dose for elderly patients is 5 mg 8
  • Caution: Higher risk of falls and confusion in elderly patients, especially at doses >10 mg 8

Remember that sedative choice should be guided by the specific symptom being targeted (anxiety, insomnia, delirium, or palliative sedation), with careful consideration of the patient's renal function, which is often compromised in multiple myeloma patients 1.