What are the contraindications for short-term benzodiazepine (BZD) prescription?

Contraindications for Short-Term Benzodiazepine Prescription

Benzodiazepines are absolutely contraindicated in patients with acute narrow-angle glaucoma and hypersensitivity to benzodiazepines, and should be avoided in patients with severe respiratory insufficiency, decompensated liver disease, and those with current or remote substance use disorders. 1, 2

Absolute Contraindications

• Acute narrow-angle glaucoma - This is an FDA-labeled absolute contraindication 1
• Known hypersensitivity to benzodiazepines or formulation components 1

Critical Clinical Contraindications (Avoid Use)

Respiratory Compromise

• Baseline respiratory insufficiency (asthma, COPD, sleep apnea) - Benzodiazepines cause respiratory depression that is particularly dangerous in critically ill patients with compromised respiratory function 2
• Combination with opioids or other CNS depressants - This significantly increases risk of dangerous respiratory depression and overdose 2, 3

Hepatic Dysfunction

• Decompensated liver disease - All benzodiazepines are metabolized by the liver, and clearance is significantly reduced in hepatic dysfunction 2, 4
• Cirrhosis - The French Association for the Study of the Liver specifically notes that decompensated liver disease must encourage prioritization against benzodiazepine use 2
• Active metabolites (particularly from diazepam and midazolam) accumulate with prolonged administration, especially when renal dysfunction coexists with liver disease 2, 4

Substance Use Disorders

• Current or remote history of alcohol or drug abuse - Dependent personalities pose a higher risk of benzodiazepine addiction 5, 6
• Patients with substance use disorders are more likely to develop benzodiazepine abuse (15% vs 6% in those not prescribed benzodiazepines) 7
• Caution is mandatory - alternatives to benzodiazepines are preferable in this population and may include antidepressants, anticonvulsants, buspirone, or antihypertensive agents 6

High-Risk Populations Requiring Extreme Caution

Pregnancy and Nursing

• Not recommended during pregnancy or nursing 2

Elderly Patients

• Elderly patients are significantly more sensitive to sedative effects of benzodiazepines 2, 4
• Caution and downward dosage adjustment is advised (e.g., 0.5 mg estazolam, 7.5 mg temazepam, 0.125 mg triazolam instead of standard doses) 2
• Start with lowest possible doses (0.25-0.5 mg lorazepam) if absolutely unavoidable 4

Depression

• Signs or symptoms of depression warrant caution, as benzodiazepines have no antidepressant properties and may worsen outcomes 2

Pediatric Patients

• Safety and effectiveness in patients <18 years not established 2

Common Clinical Pitfalls to Avoid

• Combining with alcohol - Additive effect on psychomotor performance and increased risk of respiratory depression 2, 3
• Propylene glycol toxicity - Parenteral lorazepam formulations can cause metabolic acidosis and acute kidney injury at doses as low as 1 mg/kg/day 2, 4
• Abrupt discontinuation - Rapid dose decrease or abrupt discontinuance can produce withdrawal symptoms including rebound insomnia and seizures 2
• Prescribing without considering alternatives - Many patients receive benzodiazepines without ever receiving evidence-based first-line treatments like psychotherapy, relaxation techniques, or serotonergic agents 3

Algorithm for Decision-Making

1. Screen for absolute contraindications (narrow-angle glaucoma, hypersensitivity) - if present, do not prescribe 1
2. Assess respiratory status - if compromised respiratory function or concurrent opioid use, avoid benzodiazepines 2
3. Evaluate liver function - if decompensated liver disease or cirrhosis, avoid benzodiazepines 2, 4
4. Screen substance use history - if current or remote alcohol/drug abuse, strongly prefer alternatives 5, 6, 7
5. Consider patient age - if elderly, use extreme caution with reduced doses if absolutely necessary 2
6. Limit duration - prescribe for shortest duration possible (ideally <2-4 weeks maximum) 8, 3