Benzodiazepines

Summary

Benzodiazepines are a class of medications that typically end in -pam (like diazepam and lorazepam) or -lam (like alprazolam, midazolam, and triazolam). Other important names to know include chlordiazepoxide and clorazepate.

Benzodiazepines work by enhancing the effects of GABA, the brain’s main inhibitory neurotransmitter. This causes an overall decrease in brain activity.

Clinically, benzodiazepines are used to treat anxiety, insomnia, seizures, including status epilepticus, alcohol withdrawal, and muscle spasms. They are also used for anesthesia induction before surgery. Due to their high risk of dependence, benzodiazepines are generally reserved for short-term use.

Common side effects of benzodiazepines include amnesia, sedation, dependence, and respiratory depression.

In cases of overdose, the antidote is flumazenil—though it must be used cautiously due to seizure risk in dependent patients.

When taking benzodiazepines, patients should avoid alcohol and take care not to stop benzodiazepines abruptly. Withdrawal can be dangerous, so doses must be tapered gradually under medical supervision.

Key Points

• Benzodiazepines
  • Drug Names
    • -pam
      • Diazepam (Valium)
      • Lorazepam (Ativan)
      • Oxazepam (Serax)
      • Clonazepam (Klonopin)
      • Temazepam (Restoril)
    • -lam
      • Alprazolam (Xanax)
      • Midazolam (Versed)
      • Triazolam (Halcion)
    • Chlordiazepoxide (Librium)
    • Clorazepate (Tranxene)
  • Mechanism
    • Increases effects of GABA
      • Enhance the effect of gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the central nervous system
      • GABA reduces neuronal excitability throughout the nervous system
      • Benzodiazepines bind to GABA receptors, resulting in increased frequency of chloride channel opening, leading to hyperpolarization of neurons and decreased neuronal firing
  • Clinical Use
    • Only For Short Term Use due to high risk of dependence
      • Seizures (antiepileptic)
        • Status Epilepticus (acute prolonged seizure)
        • IV benzodiazepines (usually lorazepam or diazepam) are first-line treatment
        • Rapid action helps to stop seizure activity quickly
      • Anxiety
        • Used for short-term management of acute anxiety and panic attacks
      • Alcohol Withdrawal
        • Used to manage symptoms of alcohol withdrawal syndrome, including anxiety, tremors, and seizures
      • Insomnia (sedative hypnotic)
      • Anesthesia Induction
        • Administered before surgery to reduce anxiety and induce amnesia
      • Muscle Spasms (muscle relaxant)
        • Can help relieve muscle tension and spasms
        • Often used for back pain or other musculoskeletal conditions
  • Side Effects
    • Sedation/Drowsiness
      • Patient should not drive
      • Take at bedtime to avoid daytime drowsiness
    • Amnesia
      • Can cause anterograde amnesia, meaning memory loss following administration
      • This effect is sometimes utilized purposefully in procedural sedation
    • Dependence
      • Long-term use can lead to physical and psychological dependence
      • High risk of dependence and abuse
        • Risk factors include history of substance abuse and certain psychiatric conditions
      • Schedule IV controlled substance
    • Respiratory Depression
      • Particularly dangerous in patients with respiratory conditions or when combined with opioids or alcohol
  • Antidote
    • Flumazenil
      • Competitive antagonist at the benzodiazepine receptor
      • Used to reverse benzodiazepine overdose or excessive sedation
      • Caution: can precipitate seizures in patients physically dependent on benzodiazepines
  • Nursing Considerations
    • Avoid alcohol
      • And other CNS depressants (barbiturates, opioids, etc.)
      • Combination can lead to severe respiratory depression and potentially death
    • Do not stop abruptly
      • Dose must be tapered off gradually over several weeks to avoid withdrawal effects
      • Withdrawal symptoms can include rebound anxiety, insomnia, tremors, and in severe cases, seizures