What are the indications for long-term use of benzodiazepines (Benzodiazepines)?

From the Guidelines

Benzodiazepines should not be used for the treatment of chronic insomnia disorder due to the substantial risks of dependency, falls, cognitive impairment, and other adverse effects outweighing the benefits, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.

Indications for Long-Term Use

Despite general recommendations against long-term use, chronic benzodiazepine use may be appropriate for certain patients, including:

• Treatment-resistant anxiety disorders, panic disorder, or generalized anxiety disorder that has failed to respond to first-line treatments like SSRIs or SNRIs
• Patients with certain seizure disorders, particularly those with refractory epilepsy
• Some movement disorders like stiff person syndrome or certain forms of dystonia
• Patients with severe sleep disorders that haven't responded to other interventions, under close supervision
• End-of-life care or palliative situations for symptom management
• Patients who have been on benzodiazepines for many years and face significant challenges with discontinuation due to physiological dependence, withdrawal risks, or symptom recurrence ### Considerations for Use Chronic benzodiazepine use requires careful monitoring for side effects, tolerance, dependence, and cognitive impacts, with regular reassessment of the risk-benefit ratio and attempts at dose reduction when possible 2, 3. The FDA has approved pharmacologic therapy for short-term use (4 to 5 weeks), and patients should not continue using the drugs for extended periods without further evaluation 2.

Key Points

• Benzodiazepines are not recommended for the treatment of chronic insomnia disorder due to the risks of dependency and adverse effects
• Chronic benzodiazepine use may be appropriate for certain patients, including those with treatment-resistant anxiety disorders or seizure disorders
• Careful monitoring and regular reassessment of the risk-benefit ratio are necessary for patients on long-term benzodiazepine therapy
• The FDA recommends dosages lower than those used in many studies, especially for older adults 2

From the FDA Drug Label

Indications and Usage Section INDICATIONS AND USAGE Seizure Disorders: Clonazepam is useful alone or as an adjunct in the treatment of the Lennox-Gastaut syndrome (petit mal variant), akinetic, and myoclonic seizures. In patients with absence seizures (petit mal) who have failed to respond to succinimides, clonazepam may be useful Panic Disorder: Clonazepam is indicated for the treatment of panic disorder, with or without agoraphobia, as defined in DSM-V The effectiveness of clonazepam in long-term use, that is, for more than 9 weeks, has not been systematically studied in controlled clinical trials.

The indications for long-term use of benzodiazepines, specifically clonazepam, are not established due to the lack of systematic studies in controlled clinical trials for more than 9 weeks 4.

• Seizure disorders and panic disorder are indicated uses, but the long-term effectiveness has not been studied.
• The physician should periodically reevaluate the long-term usefulness of the drug for the individual patient.

From the Research

Indications for Long-Term Use of Benzodiazepines

• Long-term low-dose benzodiazepine treatment may be necessary for some patients with anxiety disorders, as the chronic nature of anxiety may require ongoing management 5.
• Benzodiazepines can be effective and safe for long-term use in treating anxiety and related disorders, and can be combined with psychological therapy and antidepressants to produce optimal outcomes 6.
• The use of benzodiazepines as a first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder, and social anxiety disorder is supported by some studies 6.

Considerations for Long-Term Use

• Long-term benzodiazepine use can lead to dependence, withdrawal, and negative side effects, including cognitive impairment 7.
• The neuroadaptive consequences of long-term benzodiazepine use may interfere with the efficacy of antidepressants, leading to poorer depressive outcomes and functional status 8.
• Patients should be advised of the potential cognitive effects of long-term benzodiazepine use, although the impact of these effects may be insignificant in the daily functioning of most patients 7.

Pharmacological Interventions for Benzodiazepine Discontinuation

• Several pharmacological interventions, including valproate, tricyclic antidepressants, pregabalin, and paroxetine, may facilitate benzodiazepine tapering and reduce withdrawal symptoms 9.
• However, the evidence for these interventions is generally of low or very low quality, and more randomized controlled trials are needed to draw firm conclusions 9.