When should benzodiazepines (BZDs) be used?

Appropriate Indications for Benzodiazepine Use

Benzodiazepines should be used only for specific short-term indications with clear therapeutic goals, and should generally be avoided for long-term use due to risks of dependence, tolerance, and adverse effects. 1

Primary Indications for Benzodiazepine Use

• Alcohol Withdrawal Syndrome (AWS): Benzodiazepines are the first-line treatment for AWS, with long-acting benzodiazepines (chlordiazepoxide, diazepam) recommended for seizure prevention in most patients, and intermediate-acting benzodiazepines (lorazepam) recommended for patients with severe AWS, advanced age, liver failure, or serious medical comorbidities 1

• Alcohol or Benzodiazepine Withdrawal: Benzodiazepines are the treatment of choice as monotherapy for these specific withdrawal syndromes 1

• Acute Severe Agitation with Risk of Harm: May be used as crisis medication in the management of delirious patients with severe agitation and distress when the patient poses a risk to themselves or others, but only after behavioral interventions have failed 1

• Short-term Insomnia: Limited to transient or short-term insomnia, with prescriptions ideally limited to a few days, occasional use, or courses not exceeding 2-4 weeks 1, 2

• Acute Anxiety States: For acute stress reactions, episodic anxiety, or as initial treatment for severe panic, given in single doses or very short courses (1-7 days) 2

Important Limitations and Precautions

• Duration of Treatment:

  • For insomnia: Limit to 2-4 weeks maximum 1, 2, 3
  • For anxiety: Short courses (2-4 weeks) and only rarely for longer-term treatment 2

• Avoid in Older Adults: High-potency, long-acting, or prolonged use of benzodiazepines are considered high-risk in older patients due to increased risk of falls, cognitive impairment, and reduced mobility 1

• Contraindications:

  • Severe pulmonary insufficiency
  • Severe liver disease
  • Myasthenia gravis
  • Patients with history of substance abuse 1, 4

Risks and Adverse Effects

• Dependence and Withdrawal: Physical dependence can develop even after relatively short-term use (2-4 weeks) 5, 4, 3

• Withdrawal Symptoms: Include seizures, anxiety, insomnia, sensory hypersensitivity, paresthesias, muscle cramps, diarrhea, blurred vision, and in severe cases, delirium tremens 5, 4

• Cognitive Effects: Memory disruption, psychomotor impairment, increased risk of accidents 3, 6

• Paradoxical Reactions: Can cause increased agitation, hostility, and anxiety in some patients 3, 6

• Falls and Injuries: Particularly concerning in older adults 1

Specific Recommendations for Different Clinical Scenarios

• For Alcohol Withdrawal:

  • First-line treatment with psychiatric consultation recommended 1
  • Long-acting benzodiazepines (chlordiazepoxide, diazepam) for most patients
  • Lorazepam for patients with liver failure, respiratory failure, advanced age, or serious comorbidities 1

• For Delirium with Agitation:

  • Use only after non-pharmacological approaches have failed
  • Use the lowest effective dose for the shortest possible time
  • Midazolam 2.5 mg SC/IV or lorazepam 1 mg SC/IV as needed, with lower doses in elderly or frail patients 1

• For Insomnia:

  • Should be supplemented with behavioral and cognitive therapies
  • Short-intermediate acting agents preferred (temazepam, loprazolam, lormetazepam)
  • Avoid potent, short-acting benzodiazepines like triazolam which carry greater risks 1, 2

Alternatives to Consider Before Using Benzodiazepines

• For Anxiety: Psychological treatments, antidepressants, and other non-benzodiazepine medications should be considered first-line 2, 3

• For Insomnia: Cognitive behavioral therapy for insomnia (CBT-I), stimulus control therapy, relaxation therapy, and sleep restriction are recommended as initial interventions 1

• For Older Adults: Consider psychological or alternative pharmacological treatments including antidepressants, cognitive-behavioral therapy, or integrative strategies 1

Key Points for Safe Prescribing

• Use the lowest effective dose for the shortest duration possible 7
• Regularly reassess the need for continued treatment 1
• Taper gradually when discontinuing to minimize withdrawal symptoms 4
• Be aware that benzodiazepines can themselves cause delirium and increased agitation 1
• Avoid combining with other CNS depressants, especially opioids 4