Deprescribing Benzodiazepines: New Primary Care Guidelines Issued

Nicola M. Parry, DVM

May 15, 2018

A new clinical practice guideline focuses on helping clinicians to safely deprescribe benzodiazepine receptor agonists (BZRAs), including benzodiazepines, zopiclone, and zolpidem, in adult patients.

The guideline's recommendations are based on data from key BZRA deprescribing trials for insomnia, as well as on analysis of reviews of BZRA harms, patient preferences, and resource implications.

Kevin Pottie, MD, MClSc, CCFP, FCFP, from the University of Ottawa, Ontario, Canada, and colleagues published the evidence-based guideline in the May issue of Canadian Family Physician, observing that BZRAs are still widely prescribed as a long-term treatment for insomnia in adults both in the community and in long-term care.

However, although short-term (up to 6 weeks) use of BZRAs for insomnia can result in improvements in sleep onset latency of 4 minutes and an additional hour of sleep duration, their prolonged use may lead to physical and psychological dependence, they say.

In addition, recent evidence suggests that the effectiveness of these drugs for insomnia wanes in 4 weeks, but their adverse effects might persist.

In elderly patients, use of these agents has been associated with falls, dementia, motor vehicle accidents, and physical addiction, the authors note, but data show such harms are often overlooked, especially in older patients.

"This guideline outlines these harms and, through a systematic review, demonstrates the efficacy of deprescribing using tapering regimens in patients who were willing to enter deprescribing trials," the authors explain, noting that no evidence-based guidelines currently exist to advise clinicians about how to deprescribe BZRAs.

"Many patients are willing to stop taking BZRAs when they can expect improvements in cognition and reductions in other side effects," they observe. "The tools provided with this guideline — a decision-support algorithm and a corresponding patient information pamphlet — are intended to support clinicians in engaging with patients about this important topic and implementing deprescribing plans with them."

Consensus Process Identifies Benzodiazepines as Key to Deprescribe

Pottie and colleagues say that Choosing Wisely Canada recommends that BZRAs be avoided as first-line treatment of insomnia in older persons, and that in 2015, benzodiazepine receptor agonists were selected in a Canadian consensus process among family physicians, pharmacists, nurses, and geriatricians as the most important medication class for developing a deprescribing guideline.

The overall team formulating the new guideline comprised eight clinicians (one family physician, two psychiatrists, one clinical psychologist, one clinical pharmacologist, two clinical pharmacists, and one geriatrician) and a methodologist.

It focuses on adults older than 18 years, especially elderly adults (aged 65 years and older), receiving a BZRA to treat either primary insomnia or insomnia associated with underlying comorbidities.

During the guideline development process, review of the evidence failed to identify substantial harms for BZRA deprescribing in adults, the authors say. They rated the recommendation to taper the dose of BZRA in elderly patients as "strong."

In contrast, they rated the recommendation to deprescribe BZRAs in younger adults as "weak" because of the lower risk for adverse effects associated with prolonged use of these drugs in this population.

According to the guideline recommendations, clinicians should discuss the need to slowly taper BZRAs in all elderly patients (aged 65 years and older), regardless of treatment duration, as well as in those aged 18 to 64 years who have used these drugs for longer than 4 weeks.

However, the authors emphasize that this guideline does not apply to patients with other sleeping disorders, unmanaged anxiety or depression, or other physical or mental health conditions that might cause or aggravate insomnia.

No Information on Tapering Doses, but Algorithm Helps With Expectations

The authors suggest that clinicians should offer a BZRA deprescribing strategy to all eligible adult patients,

However, they say their review failed to identify trials comparing different tapering approaches. Nevertheless, they recommend that clinicians consider using a slower rate (potentially over several months) with patients who have a higher risk for relapse, including those with a history of psychological distress or long-term BZRA use.

During the tapering phase, the deprescribing algorithm indicates the need for clinicians to monitor patients every 1 to 2 weeks for expected benefits (including improvements in cognition, alertness, daytime sedation, and the incidence of falls) and withdrawal symptoms (including insomnia, anxiety, irritability, sweating, and gastrointestinal symptoms).

The authors also suggest that clinicians consider using behavior management strategies to help patients with insomnia.

Indeed, their systematic review showed that use of cognitive behavioral therapy in combination with BZRA tapering improves postintervention BZRA cessation rates compared with BZRA tapering alone.

Patient Information Pamphlet Developed

Because patients and their families should play a central role in the decision to continue, taper, or stop BZRAs, Pottie and colleagues developed a patient information pamphlet to help clinicians to guide these discussions.

"Such engagement strategies (aimed at educating patients regarding BZRA use and involving them in tapering plans) have been employed as part of tapering interventions with success," they say.

Although the authors believe that this new guideline will help clinicians initiate discussions about BZRA deprescribing with patients, they acknowledge that gaps remain regarding this strategy.

"The [Guideline Development Team] will provide routine guideline updates as new evidence emerges that might change the recommendations," they conclude, adding that prospective evaluation of the effects of this, and other deprescribing guidelines "will be part of a research strategy in the future."

This study was supported by the Government of Ontario. Several authors have reported receiving funding from the Institute for Healthcare Improvement, The Commonwealth Fund, the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and Pfizer Canada. One author has reported receiving financial payments for speaking engagements from the Ontario Long Term Care Physicians Association, the Ontario Pharmacists Association, and the Canadian Society of Hospital Pharmacists. Another author has reported being a member of the Alberta Expert Committee on Drug Evaluation and Therapeutics. The remaining authors have reported no financial conflicts of interest.

Can Fam Physician. 2018;64:339-351. Full text

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