BENZODIAZEPINES

Benzodiazepines are useful drugs in terminal care, provided they do not become substitutes for the counseling, discussion and continuing reassurance needed by an anxious and distressed terminally ill patient.

«  Writing a prescription for benzodiazepines is not an appropriate reply to the difficult questions a terminally ill patient often asks the doctor.

General uses:

  •  Night sedation (temazepam, triazolam)

  •  Anxiolytic (diazepam, lorazepam)

  •  Muscle relaxant (diazepam)

  •  Anti-convulsant (clonazepam, diazepam)

Special uses:

Clonazepam is reserved for use as an anti-convulsant.

Diazepam (usual dose 5mg to 10mg at bedtime) is useful to reduce anxiety and control muscle spasms.

Rectal diazepam enema 10mg is useful for control of seizures and works as quickly as an IV injection. (Diazepam enemas are not available commercially in the United States, but enterprising pharmacists can prepare them for use in hospice and palliative care.)

Lorazepam is less cumulative than diazepam, and is usually the anxiolytic of choice. The oral dose is 0.5mg to 2mg, usually every 4 to 6 hours (but may be needed every 2 to 3 hours). Lorazepam 1mg to 2mg IV is useful for urgent sedation.

Midazolam is water soluble, and can be used in a continuous subcutaneous infusion (usual starting dose is 20mg to 30mg per 24 hours).

Temazepam (15mg to 60mg) is the most useful drug for night sedation for the majority of patients. A few patients find even temazepam 15mg causes a “hangover” effect the next morning, in which case use triazolam 0.125mg to 0.5mg at bedtime.

Some long-acting benzodiazepines (those with half-lives above 25 hours) are converted into active metabolites with very long half-lives. Diazepam is converted into desmethyldiazepam with a half-life of about 150 hours!

Half-lives of some commonly used benzodiazepines:

Diazepam 40 hours
Lorazepam

20 hours

Temazepam

13 hours

Triazolam 3 hours
Midazolam 3 hours

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.


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