Sedative Hypnotics including Benzodiazepines

Intoxication with the sedative-hypnotic drug class causes slurred speech, ataxia, respiratory depression, stupor, coma, and death (mostly with mixed overdose). Treatment of overdose involves providing respiratory support and gastrointestinal (GI) tract evacuation. Activated charcoal is particularly helpful for barbiturate overdose, as is urine alkalization for phenobarbital overdose. Flumazenil, a benzodiazepine receptor antagonist, can be used in benzodiazepine overdose, but with caution because it can dramatically increase the risk of seizures and cardiac arrhythmias, especially in mixed overdoses and in patients physiologically dependent on benzodiazepines (Ries et al., 2009).

Withdrawal signs and symptoms from sedative-hypnotics include tachycardia, hypertension, fever, agitation, anxiety, hallucinations, insomnia, irritability, nightmares, sensory disturbances, tremor, tinnitus, anorexia, diarrhea, nausea, seizures, delirium, and death. Most sedative-hypnotic withdrawal is managed by either simple, slow, fixed-dose taper or substitution and taper. A simple taper involves decreasing the dose by no more than 10% every 1 to 2 weeks until the starting dose has been 75% decreased, then by 5% every 2 to 4 weeks for the last 25% until the taper is completed. Substitution and taper involves substituting a long-acting benzodiazepine (e.g., clonazepam) or phenobarbital for a shorter-acting drug and tapering as above. Conversion tables are available to calculate an approximate equivalent dose, and the dose is titrated over several days to a week, to achieve good relief of withdrawal symptoms before tapering is begun of the substitute, as with the simple taper method. Other adjunctive medications that have shown positive effects include carbamazepine, sodium valproate, propranolol, and trazodone. Because many patients dependent on benzodiazepines in particular have underlying anxiety and other psychiatric comorbidities, and because withdrawal protocols are typically prolonged, anticipation and treatment of reemergence of these symptoms must be anticipated, or relapse is more likely (Ries et al., 2009).

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