Weve done many columns on potentially inappropriate medications in the elderly. One class of drugs that always appears on all such lists is benzodiazepines and benzodiazepine receptor agonists. That includes those that are used for promoting sleep, including benzodiazepines, zopiclone, and zolpidem. Such are intended for short-term use but, unfortunately, many patients end up taking them chronically. Weve described the safety issues associated with these in multiple columns (listed below).
An excellent evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists was recently published in the journal Canadian Family Physician (Pottie 2018). They note the harms associated benzodiazepine receptor agonists include physical dependence, drowsiness, balance issues, falls, fractures, cognitive impairment, memory disorders (including anterograde amnesia), functional impairment, and motor vehicle accidents. They conducted a systematic review of benzodiazepine receptor agonist (BZRA) deprescribing trials for insomnia, as well as performing a review of the harms of continued BZRA use. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used for guideline development.
The guideline recommends that deprescribing (tapering slowly) of BZRAs be offered to elderly adults (≥ 65 years) who take BZRAs, regardless of duration of use, and suggest that deprescribing (tapering slowly) be offered to adults aged 18 to 64 who have used BZRAs for more than 4 weeks. Note that the recommendations apply to patients who use BZRAs to treat insomnia on its own (primary insomnia) or comorbid insomnia where potential underlying comorbidities are effectively managed. It does not apply to those with other sleep disorders or untreated anxiety, depression, or other physical or mental health conditions that might be causing or aggravating insomnia.
The Canadian guideline article also notes the potential financial savings from deprescribing BZRAs. That includes not just the cost of the drugs themselves but the savings from fewer resultant falls and other adverse patient events.
The guideline comes with an algorithm for deprescribing that includes recommendations about the tapering and need to monitor the patient every 1-2 weeks for the duration of the tapering process. The notes attached to the guideline have a list of the commonly used offending drugs and excellent tips on how to promote sleep non-pharmacologically, both in primary care and institutional settings. It also includes notes about the role of cognitive behavioral therapy (CBT).
The Pottie article also acknowledges the importance of the discussion that needs to take place with patients about deprescribing. Any decision needs to be based on a balance of knowledge about a drugs indication and effectiveness, as well as risks of use (actual or potential side effects), drug interactions, pill burden, and cost. Decisions also need to take into account patient or family values and preferences as part of shared decision making. The authors note they have developed a patient pamphlet to help with these discussions.
This is a well-referenced and resourced article with excellent recommendations about helping our patients discontinue drugs that may likely have outlasted their temporary benefits but are still putting our patients at risk of many potential adverse consequences.
For more on deprescribing, see our past columns listed below. Also, ISMP Canada (ISMP Canada 2018) recently published a Safety Bulletin that had links to many excellent deprescribing resources that you will find very valuable. One of the linked resources is a toolkit for deprescribing benzodiazepines in older adults put out by Choosing Wisely Canada. Choosing Wisely Canada has also developed several other toolkits for deprescribing other drugs.
Some of our past columns on deprescribing:
Some of our previous columns on safety issues associated with sleep meds:
August 2009 Bold Experiment: Hospitals Saying No to Sleep Meds
March 23, 2010 ISMP Guidelines for Standard Order Sets
May 2012 Safety of Hypnotic Drugs
November 2012 More on Safety of Sleep Meds
March 2013 Sedative/Hypnotics and Falls
June 2013 Zolpidem and Emergency Room Visits
August 6, 2013 Let Me Sleep!
June 3, 2014 More on the Risk of Sedative/Hypnotics
May 15, 2018
Some of our past columns on Beers List and Inappropriate Prescribing in the Elderly:
Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists. Evidence-based clinical practice guideline. Canadian Family Physician 2018; 64(5): 339-351
ISMP Canada. Deprescribing: Managing Medications to Reduce Polypharmacy. ISMP Canada Safety Bulletin 2018; 18(3): 1-4 March 28, 2018
Choosing Wisely Canada. DROWSY WITHOUT FEELING LOUSY. A toolkit for reducing inappropriate use of benzodiazepines and sedative-hypnotics among older adults in primary care. July 2017