Benzodiazepines tend to garner a bad reputation on inpatient services perhaps because of individual patients with substance use disorders who abuse them. This may creates unpleasant memories for physicians with respect prescribing benzodiazepines for patients with future. However, benzodiazepines are an excellent short-term treatment for anxiety or agitation on inpatient services.★ Surprisingly, the incidence of addiction for benzodiazepines (in the absence of any previous substance use disorders) is relatively low, less than 20%. Thus, for symptoms of anxiety that are clearly related to a medical or postsurgical condition, then today's opinions represented the small short-term treatment. Of course, longer country that would necessitate the use of other agents, such as SSRIs. Over the short term, however, tolerance really isn't much of an issue with benzodiazepines. It may be the case that many humans could benefit from an SSRI, but sometimes one is not always necessary.
Benzodiazepines tend to be rapidly absorbed in the G.I. tract. Somewhat ironically, intramuscular absorption can be rather variable, except for lorazepam and midazolam, which are readily absorbed intramuscularly. ★Diazepam is poorly absorbed intramuscularly, and that should be given either orally or intravenously. Distinctions among different benzodiazepines are largely based on half-life, time to peak level, and method of metabolism. Some benzodiazepines, such as diazepam and alprazolam have fairly rapid initial onset. As described in the table here, half-life can vary significantly because of active metabolites of different compounds. Notably, lorazepam and oxazepam do not have any active metabolites, which makes them more suitable for use in patients with hepatic dysfunction.
Metabolism of most benzodiazepines slows with age, although this is less the case with those compounds oxidized through glucuronic conjugation.
cautions
Benzodiazepines are contraindicated in patients with sleep apnea because of elevated carbon dioxide levels present further complications with the decrease in respiratory drive generated by benzodiazepines. in addition, there is an FDA warning regarding the administration of intramuscular benzodiazepines in conjunction with intramuscular olanzapine. The concern is over a decrease in respiratory drive, though many clinicians still administer this combination of medications if agitation is extreme (though it is not recommended for use in patients with chronic obstructive pulmonary disease).
withdrawal
Withdrawal from benzodiazepines can be clinically significant, and the likelihood of withdrawal symptoms increases with dosage, duration of treatment, and the rapidity with which the drug is discontinued. Benzodiazepine withdrawal includes dizziness, sweating, shakiness, headache, blurred vision, and tinnitus. The most serious forms of withdrawal can also lead to seizures. As might be expected, the withdrawal symptom is worse for benzodiazepines with short half-lives, and especially so with alprazolam. Some people have suggested that alprazolam may be on the darker side of evil, because of the challenges involved and it discontinuing therapy with it.
In general, withdrawal from benzodiazepines is made simpler by converting a patient to an equivalent dose of a longer acting agent. The longer acting benzodiazepine can be tapered so as to avoid discomfort and seizures.
pregnancy
★Benzodiazepines should not be used continuously during the first trimester, although they can be justified during the second and third trimesters in patients with severe panic attacks or strict bed rest. Benzodiazepine use at the time of delivery can lead to 'floppy baby syndrome.' Benzodiazepines should be avoiding if a patient is breastfeeding.