Benzodiazepine withdrawal: Difference between revisions
| Line 24: | Line 24: | ||
*Ensure patient and staff safety, airway protection if acutely agitated or seizing | *Ensure patient and staff safety, airway protection if acutely agitated or seizing | ||
*[[Benzodiazepines]] | *[[Benzodiazepines]] | ||
** | **Mild, can tolerate PO: Long-acting [[benzodiazepine]] (e.g., [[chlordiazepoxide]]) | ||
**Consider substituting shorter half-life drugs with equivalent dose of [[diazepam]] | **Moderate/severe: IV [[diazepam]] | ||
**Equivalent diazepam dose = [[triazolam]] dose x 20 = [[alprazolam]] dose x 10 = [[lorazepam]] dose x 5 | ***Consider substituting shorter half-life drugs with equivalent dose of [[diazepam]] | ||
*After acute symptoms controlled, can prescribe gradual | ***Equivalent [[diazepam]] dose = [[triazolam]] dose x 20 = [[alprazolam]] dose x 10 = [[lorazepam]] dose x 5 | ||
*After acute symptoms controlled, can prescribe gradual [[benzodiazepine]] taper | |||
**One taper strategy: decrease dose by 25% for first week, 25% second week, then by 12.5% for subsequent weeks<ref>Chang F: Strategies for benzodiazepine withdrawal in seniors. CPJ 138: 38, 2005. | **One taper strategy: decrease dose by 25% for first week, 25% second week, then by 12.5% for subsequent weeks<ref>Chang F: Strategies for benzodiazepine withdrawal in seniors. CPJ 138: 38, 2005. | ||
</ref> | </ref> | ||
Revision as of 23:25, 14 December 2022
Background
- Very similar to alcohol withdrawal
- Occurs due to chronic use of benzodiazepines, leading to physiologic tolerance[1]
Clinical Features
- Onset usually several days to up to 3 weeks
- More likely in patients with high doses or prolonged use
- Autonomic hyperactivity (e.g., diaphoresis, HR>100, hyperthermia)
- Nausea/vomiting
- Tremulousness, psychomotor agitation
- Anxiety, insomnia, irritability, agitation
- Psychosis (more common than in ETOH withdrawal)
- Seizure
Differential Diagnosis
Sedative/hypnotic withdrawal
- Toxic alcohols
- Benzodiazepines
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
- Baclofen
- Barbiturates
- Opioids
- Chloral hydrate
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
- Evaluate for other causes of and complications of symptoms (see evaluation of seizure, altered mental status, hypertension, hyperthermia
Management
- Ensure patient and staff safety, airway protection if acutely agitated or seizing
- Benzodiazepines
- Mild, can tolerate PO: Long-acting benzodiazepine (e.g., chlordiazepoxide)
- Moderate/severe: IV diazepam
- Consider substituting shorter half-life drugs with equivalent dose of diazepam
- Equivalent diazepam dose = triazolam dose x 20 = alprazolam dose x 10 = lorazepam dose x 5
- After acute symptoms controlled, can prescribe gradual benzodiazepine taper
- One taper strategy: decrease dose by 25% for first week, 25% second week, then by 12.5% for subsequent weeks[2]
- Consider neurology consult if patient was using benzos for seizure control (may need further antiepileptic management)
Disposition
- Admit if:
- Multiple seizures
- Uncontrolled autonomic hyperstimulation
- Decreased level of consciousness