Deprescribing Benzodiazepines: Changing Attitudes

Linda Brookes, MSc

Disclosures

June 15, 2018

The Deprescribing guidelines for the elderly project, based at the Bruyère Research Institute in Ottawa, Ontario, Canada, has developed a series of clinical practice guidelines to support healthcare professionals' efforts to discontinue certain medications, particularly in adults over age 65. The next in this series focuses on benzodiazepine receptor agonists and the problem of long-term use by adults who were initially prescribed the drugs to treat insomnia.[1] The guideline is published with accompanying decision-support algorithms [2] and a patient information pamphlet.[3] Lead author Kevin Pottie, MD, spoke with Medscape about the importance of a rigorous, evidence-based guideline that provides support during discussions with patients about deprescribing these drugs. Dr Pottie is associate professor in the Departments of Family Medicine and Epidemiology & Community Medicine at the University of Ottawa.

Four other guidelines in the series[4,5,6,7] discuss deprescribing proton pump inhibitors, antihyperglycemics, cholinesterase inhibitors, and antipsychotics.

Deprescribing Benzodiazepines

Benzodiazepines and the newer benzodiazepine receptor agonists, zolpidem, zopiclone, and zaleplon — the so-called "Z drugs" — are used widely throughout the United States and Canada, especially in older patients, among whom they rank among the top 10 drugs prescribed.[8] In the United States, about 5% of all adults have been prescribed a benzodiazepine,[9,10] but the rate rises to almost 9% in those who are 65 to 80 years of age.[10] The proportion of those older than age 65 years using benzodiazepines in Canada is even higher, at 14%, although this represents an ongoing decline nationally in this group.[8]

Benzodiazepines are approved only for short-term use, in part because of the demonstrated loss of therapeutic effect as early as 4 weeks, and because of the risks for cognitive impairment, falls, fractures, and car accidents, as well as the abuse and dependence liability associated with the drugs, especially in the elderly.[11] Benzodiazepines have also been implicated in the development of dementia, infections, pancreatitis, and cancer, and exacerbation of respiratory disease.[11,12]Nonetheless, long-term use of benzodiazepines is common and markedly increases with age.[8,10]

Focus on Insomnia

Although the older benzodiazepines are prescribed for a range of conditions, anxiety in particular, the new deprescribing guideline is limited to adults who were originally prescribed a benzodiazepine, or zolpidem or zopiclone, the Z drugs available in Canada, to treat insomnia. "In order to create an evidence-based process, you need a defined condition and then you need to be able to conduct a systematic review around that condition," Dr Pottie explained. "By focusing on insomnia, we capture a lot of people who may have been erroneously prescribed these drugs and have never had them stopped." Many patients are prescribed benzodiazepines for a range of conditions that are not well-specified, he noted. "We are dealing with a very large problem of inheriting older practices; that is why this will continue to be important."

A number of US and Canadian professional medical organizations, including those associated with geriatrics and psychiatry, recommend against using benzodiazepines as a first-line intervention for insomnia in older adults.

Nowadays, a number of US and Canadian professional medical organizations recommend against using benzodiazepines as a first-line intervention for insomnia in older adults.[13,14,15] The American Geriatrics Society specifically advises avoiding the Z drugs "because of their association with harms balanced with their minimal efficacy in treating insomnia."[16] A 2007 review suggested that all the hypnotic drugs have similar effects in chronic insomnia, but that the newer, nonbenzodiazepine drugs may be safer.[17] However, "There has been a lot of debate over the years about this, but we are actually finding similar challenges with the newer drugs," Dr Pottie noted.

Policy Change Requires High Quality of Evidence

"We have been saying for years that people should stop these drugs," Dr Pottie said. "But we didn't say it with the evidence, the force, and the shared decision-making that we now have with these guidelines, so we didn't really have enough power to make a major impact. Now it feels like it is part of good practice and I am convinced, based on all the research, that it is an important thing to offer people."

In order to conduct a rigorous systematic review of evidence, Dr Pottie and his colleagues identified 13 studies that provided the basis for producing recommendations based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) quality of evidence ratings.[18] "But we found gaps, particularly in comparisons of tapering strategies and studies of outcomes such as quality of life, so we need more research to give more precision," Dr Pottie added.

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