Recommend Deprescribing Continue BZRA

[Pages:2]Is a Benzodiazepine or Z-Drug still needed for sleep?

August 2018

What are BenzodiazWephiyneis&pZat-iDernutgtsak(BinZgRAa sB)?ZRA? Stopping a BZRA is not for everyone

Benzodiazepine receptor agoniIsf tusns&uZre-D, rfuingdso, uotriBf hZiRsAtosr,yaorfeaanxcielatys,spoafsdt prusgycshiatrist coSnsoumlte, wphaettiehnertsmmayahyanveeebdeeton ssttaaryteodnina hBoZsRpAitafol rfoar very specific reason.

that are used to treat problemsssleuecph, oarsfoarngxriieetfyreoarcdtiioffnic. ulty sleeping.

However, most need a BZRA for a short period of time.

There are many different types of BZRA drugs:

People who may need to continue on a BZRA include those with any of the

? Insomnia on its own OR insomnia where underlying comorbidities managed

following:

? Other sleeping disorders (e.g. restless legs)

?FAorlptrhaozsoelam6(5Xayneaxrs?)of age: taking BZRA re?gLaordralezesspaomf d(uArtaivtiaonn?()avoid

?FBorrotmhoaszeep18am-64(Lyeecatorspaomf a?g)e: taking BZRA?> 4Nwitreaezkespam (Mogadon?)

? Chlordiazepoxide (Librax?)

? Oxazepam (Serax?)

as

first

line

therapy

i?n

oUlndmerapneaogpedle)anxiety,?deUpnrmesasnioange, pdhaynsxicieatlyo, rdmepernetsaslicoonn, dpihtiyosnictahlaotrmmaeynbtael condition that may be causing or aggravating insomnia

causing or aggravatin?gBinesnozmodniiaazepine effective specifically for anxiety

Engage patients ? Clonazepam (Rivotril?)

? Clorazepate (Tranxene?)

? Temazepam (Restoril?)

? Anxiety that has been?sApleccoihficoal lwlyitahnddraewffaelctively managed with the BZRA

(discuss pote?ntTiraial zrioslkasm, b(Henaelcfiiotsn,?w) ithdrawal plan, symptoms?anAdlcdohuroaltwiointh)drawal

? Diazepam (Valium?)

? Zopiclone (Imovane?, Rhovane?)

Recommend Deprescribing ? Flurazepam (Dalmane?)

? Zolpidem (Sublinox?)

How to safely reducCeoantBinZuReABZRA

People between 18 and 64 yea?rsMoinf iamgiezewuhsoe hofadvreubgseethnatawkoinrsgena BZRA for

Why use less of, or stop using a BZRA?

insomnia more than 4 weeks, anindsopmeonpiale(e6.g5. yceaaffresinoef,aaglceohoor loeldtce.)r taking a

Taper and then stop BZRA BZRAs used as sleeping pills are usually only helpful for a short period

(aro(tuapnedr s4lowwelyeiknsc)oollafbnoirgahtiotlnywuisthep. aAtfietentr,afofreewxamwpeleek~s2,5t%heevberryatiwnogweetsekuss, aenddtiof possible,

BZRA for insomnia regardless o? fThreoawt ulondnegr,lysihnoguclodndtaitlikonto their

12.5p%rorveidduecrtioanbsonuetarwhether

stoppi?nCgoansBiZdRerAciosntshueltirnigghptscyhchooicloegfiostr psychiatrist or sleep specialist

health othr em.

care

theeenfdfeacntds/oorfptlhanenBedZRdrAuga-fnredeidtamysa)y not work as well as it did at first, but can

Doctors, nurse practitioners or pharmacists can help to decide on the best

still caFuosretshiodeseeffec6ts5. years of age (strong recommendation from systematic review andaGpRpArDoEaacphprtooacuhs)ing less of a BZRA. They can advise on how to reduce the

BZRAsFocarnthcaoussee 1d8ep-6en4dyeenacers, moefmaogrey p(rwoebalkermecsomamndenddaatyiotinmfreomfastiygstueem.aTtihcereyview

are also associated with dementia and falls (sometimes resulting in broken

and

dose, when to use GTRhAeDyEcaapnpraolascoh)give

drug-free days, and whether to stop the drug advice on how to make lifestyle changes that

altogether. can

bonesO).ffTehrebcehhanacveioouf eraxpl esrlieeenpciinnggthaedsveiceeffe; cctosnmsaiydbeer ChiBgTheirf aasvpaeiloapblele (see remvaenrsagee) insomnia.

get older. Many countries recommend against using BZRAs for sleep in

Slowly reducing the dosIef soyfmthpteoBmZsRrAelahpeslpe:s to reduce the severity of

older people.

BeMcauosenBitZoRArsedovne'trwyor1k-a2s wwelel aeftkersa ffeowrwdeeuksraantdiobnecaousfettahepy ecarning

cauEsxepescidteedebfefencetfsit,si:t's reasonable for many people, especially older people, to tryManaydismtporpovtaekailnegrtntheessm, caongdnilteioanr,ndtaoytfiamlleasseledeatpioonnatnhderierdouwcne faagllasin.

Withdrawal symptoms: Insomnia, anxiety, irritability, sweating, gastrointestinal symptoms (all usually mild and last for days to a few weeks)

withdrawal effects. PeopCloenasirdeemr ore successful in stopping their BZRA if

theUysselnoownl-ydreudguce

peaoppplerocaacnhersedtouce sevmearnaal gmeonths.

the the

dosMeaiinnstateinaindgocfujruresnt tsBuZdRdAendloysestfoopr p1-i2ngweite.kSs,otmheen dosceonotvineurethtoe tcaopuerrsaet solfoawfreawteweeks; others need

insomnia

Alternate drugs

SwUitscehbineghafrvoiomraal short-actOinthgeBr ZmReAditcoataiolnosngh-aavcetibnegenonuesehdatsobmeaennage

recaopmprmoaecnhdeesd in the pastibnusotmhansian. Aostsbeesesnmesnhtoowfnthteoirbseafmetoyraenedffective than

sloawnldy/loorwCeBrTing the dose oefffaecsthivoernt-eascstisngbedyroungd. the scope of this algorithm.

(see reverse)

See BZRA deprescribing guideline for details.

? Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Contact deprescribing@ or visit for more information.

Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B (2016). Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. Can Fam Physician 2018;64:339-51 (Eng), e209-24 (Fr)

Is a Benzodiazepine or Z-Drug still needed for sleep?

August 2018

What to expect afteWr rheyduiscpinagtiaenBtZtRaAking a BZRA? What to do if insomnia continues

Some people may have difficulItfyusnlseuerpe,infginwdhoeunt iaf hdisotsoeryisoffairnsxtireetyd,upcaesdt ,pbsyucthiatrist coTnaslukltt,owahehtehaelrtmh acyahreavperobveiednesrtaabrtoeudtintrheaostipnigtaul fnodr erlying conditions that

many will not. Difficulty sleepinsgleteepn,dosr ftoor bgreiewf orerascttiinont.he first few days after

are affecting sleep. Avoid using other medication to treat insomnia. Most

reducing or stopping, and usually resolves in a few weeks.

sedatives contribute to sedation and increase risk of falls. Ask about

S?omInesopmenoipaleonhiatsveowonthOeRr sinysmomptnoima wshoefrwe iutnhdderarlwyinagl (ceo.mg.oarbnixdiietiteys, imrraitnaabgielidty, andFosrwtheoastieng)6; 5thyeesaerssoyfmagpeto: tmaksintegnBdZRtoA breegamrdolsetsseovfedrueraintiothne(afvirositdfaeswfidrsatylsine

"cognitive behavioural therapy" ? an educational approach that has therapby einenoldsheropwenoptoleh) elp pa??tieOUnnthtmsearsnstaolegpeepBdiZnaRgnAxdi.iesCtoyhr,dedecerkpsro(eeus.tgsi.tohrneiss, tprleehssyssoiluceargclseo)rfomremntoarle

andFogretthboesette18r -w6i4thyienarasfoefwagwee: etakksi.nIgf BaZnRyAth>i4ngwoeedkdshappens, people should

information: . tYmouaycbaencaalussoindgisocruasgsgroatvhaetirnogpintisoonmsnfioar

talk to a health care provider for advice.

managing your insomn?iaBief nitzogdeitaszwepoirnseeewffhecetnivyeosupeucsieficaallloywfoerradnoxiseetyor stop

your BZRA.

? Alcohol withdrawal

Engage patients Reducing or stopping a BZRA m(daisycuimsspproovteenatilaelrrtinsekss,sbaenndeftithsi,nwkiitnhgdraabwialiltyp,lan, symptoms and duration)

and reduce daytime sedation and fall risk.

Personalized BZRA dose reduction strategy:

Other ways toRmeacnoamge minseonmdniaDeprescribing __________________________C__o_n__t_i_n__u_e___B__Z__R_A_________________

For a person who lives in the community:

__________________________?_M__in_i_m_i_ze__u_se__o_f_d_ru_g_s__th_a_t_w_o_r_s_e_n________ insomnia (e.g. caffeine, alcohol etc.)

??TGDaoopntooebtruedsaeobnnelyddwohtrebhneedslrenoeopmsy ftoor apnytBhinZgRbuAt sleep (or intimacy)

__________________________?_T_re_a_t_u_n_d_e_r_ly_i_n_g_c_o_n_d_it_io_n_______________ ? Consider consulting psychologist or

?(tIafpneortsaloswlelyepinwcoitlhlaibno2ra0t-i3on0 wmitihn poantigeontin, fgo/rreextaumrnpilneg~t2o5%beedv,eeryxittwtohewebeekdsr,oaonmd if possible, 12.5_%__re_d_u_c_ti_o_n_s_n_ea_r______________p_s_y_c_h_ia_t_ri_st_o_r_s_l_e_e_p_s_p_e_c_ia_l_is_t___________

?eUndseanadla/romr ptloananweadkdernuga-ftretheedasyasm) e time every morning

_____________________________________________________________

? DoFonorttnhaopse 65 years of age

? Avoid caffeine after noon

(strong recommendation from systematic review and GRADE approach)

_____________________________________________________________

? AvFooidr etxheorcsisee,1n8ic-o6t4iney,eaalcroshool,f aangdebig(wmeeakalrsec2ohmomuernsdbaetifoonrefrbomedstyimstematic review and GRADE approach)

_____________________________________________________________

For a pOaftfieerntbwehhoalvivioesuirnallosnlge-eteprimngcaaredovricheo;spcoitanls: ider CBT if available (see reverse)

? Pull up curtains during the day for light exposure

? Keep alarm noises to a minimum

??MIRneocdruenaceistenoudmarybteeimrvoeefancratypivsit1(yn-o2mowreetheank3s0 mfoinurteds aunrdanotinoapns aoftefr 2tpamp) ering

?EHxpaveectwedarbmendeefciatsf:drink, warm milk at night

? ReMsatryicitmfoporodv,ecaflfeeritne,ssm, cookginigtiboenf,odreaybtiemdetimseedation and reduce falls ??WUHisathevedtorraeilwgeutallbaseryfbomerepdttgoiomminesg:atnodbreisding times ? AvInosidomwnakiain, ganaxtientigy,hitrrfiotar bdiilrietyc,t scwareeating, gastrointestinal symptoms ? Tr(yabllaucskuruablly, gmeinldtleanmdalsassatgfeor days to a few weeks)

This pamphIlfetsaycmcopmtopmansiereslaapdseper:escribing guideline and

algorithm thaCt ocannsibdeeursed by doctors, nurse practitioners, or

Use non-drug approaches to manage

phaMrmaaincitsatisntiongguciuderrednept rBeZscRrAibdinogs. e for 1-2 weeks, then continue to taper at slow rate

insomnia

Alternate drugs

Use behavioral approaches

Other mediVcaistiitons have been used to manage

deinpsormenisa.cAsrsiebssimnengt o.of thregir safety and

and/or CBT

efffoerctmivoenreesinsfiosrbmeayotinodnt.he scope of this algorithm.

(see reverse)

See BZRA deprescribing guideline for details.

? Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Contact deprescribing@ or visit for more information.

Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B (2016). Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. Can Fam Physician 2018;64:339-51 (Eng), e209-24 (Fr)

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