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

August 2018

Why is&patient
What are Benzodiazepine Z-Drugstaking a BZRA?
(BZRAs)? Stopping a BZRA is not for everyone
If unsure,
Benzodiazepine receptor agonists find out
& Z-Drugs, or ifBZRAs,
historyare
of anxiety,
a classpast psychiatrist consult,
of drugs Somewhether
patientsmay
mayhave been
need started
to stay onina hospital
BZRA forfora very specific reason.
sleep, or for grief reaction.
that are used to treat problems such as anxiety or difficulty 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)
• For those ≥ 65
Alprazolam years®)of age: taking BZRA regardless
(Xanax • Lorazepam of duration
(Ativan®(avoid
) as first line therapy in older people) • Unmanaged anxiety, depression, physical or mental
• Unmanaged anxiety, depression, physical or mental condition that may be
• For those 18-64(Lectopam
Bromazepam years of age:
®
) taking BZRA• > 4Nitrazepam
weeks (Mogadon®) condition that may be causing or aggravating insomnia
causing or aggravating insomnia
• Benzodiazepine effective specifically for anxiety
• Chlordiazepoxide (Librax®) • Oxazepam (Serax®)
• Clonazepam (Rivotril®) • Temazepam (Restoril®) Alcohol withdrawal
• Anxiety that has been• specifically and effectively managed with the BZRA
Engage patients
• Clorazepate (Tranxene®) (discuss potential risks, benefits,
• Triazolam (Halcion®) withdrawal plan, symptoms and duration)
• Alcohol withdrawal
• Diazepam (Valium ) ®
• Zopiclone (Imovane®, Rhovane®)
• Flurazepam (Dalmane®)
Recommend Deprescribing
• Zolpidem (Sublinox®)
How to safely reduce a BZRABZRA
Continue
People between 18 and 64 years of age who
• Minimize use have been
of drugs thattaking
worsena BZRA for
Why use less of, or stop using a BZRA? insomnia (e.g. caffeine, alcohol
insomnia more than 4 weeks, and people 65 years of age or older etc.) taking a
Taper
BZRAs used and then
as sleeping pillsstop BZRA
are usually only helpful for a short period
• Treat underlying condition
BZRA for insomnia regardless of how long, should talk to their health care
• Consider consulting psychologist or
(taper slowly
(around in collaboration
4 weeks) of nightly with
use.patient,
After aforfew
example ~25%
weeks, theevery twogets
brain weeks, andto
used provider
if possible, 12.5% about
reductions nearwhether stopping a BZRA is the right choice for them.
psychiatrist or sleep specialist
theend and/or
effects ofplanned drug-free
the BZRA and itdays)
may not work as well as it did at first, but can Doctors, nurse practitioners or pharmacists can help to decide on the best
For those ≥ 65 years of age (strong recommendation from systematic review andapproach
still cause side effects. to using less of a BZRA. They can advise on how to reduce the
GRADE approach)
BZRAsForcanthose
cause 18-64
dependence, dose, when to use drug-free days, and whether to stop the drug altogether.
yearsmemory
of age problems and daytime
(weak recommendation fromfatigue. They
systematic review and GRADE approach)
They can also give advice on how to make lifestyle changes that can
are also associated with dementia and falls (sometimes resulting in broken
bones).Offer
Thebehavioural sleepingthese
chance of experiencing advice; consider
effects may be CBT
higherif as
available
people (see reverse)
manage insomnia.
get older. Many countries recommend against using BZRAs for sleep in Slowly reducing the dose of the BZRA
If symptoms helps to reduce the severity of
relapse:
older people. withdrawal effects. People are more successful in stopping their BZRA if
Consider
they slowly reduce the dose instead of just suddenly stopping it. Some
Monitor
Because BZRAs every
don’t work 1-2 weeks
as well forweeks
after a few duration of tapering
and because they can
Use non-drug
approaches
people to
can reduce the dose
Maintaining current BZRA dose for 1-2 weeks, then
over the course of a few
cause side effects, rate weeks; others need
benefits:it’s reasonable for many people, especially older people,
continue to taper at slow
Expected manage
several months.
to try and stop taking them and learn to fall asleep on their own again. insomnia Alternate drugs
May improve alertness, cognition, daytime sedation and reduce falls
Switching from a short-acting
Use behavioral OtherBZRA to a long-acting
medications have beenone has
used to been
manage
Withdrawal symptoms: recommended in the past but has
insomnia.not been shown
Assessment of to
theirbe more
safety effective than
and
approaches
Insomnia, anxiety, irritability, sweating, gastrointestinal symptoms slowly lowering
and/or CBT the dose of a short-acting
effectiveness is drug.
beyond the scope of this algorithm.
(all usually mild and last for days to a few weeks) (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@bruyere.org or visit deprescribing.org 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

Why
What to expect after is patient
reducing taking a BZRA?
a BZRA What to do if insomnia continues
Some people may have difficulty If unsure,
sleeping find out ifahistory
when dose isoffirst
anxiety, past psychiatrist
reduced, but consult,
Talk towhether
a healthmay have
care been started
provider aboutintreating
hospitalunderlying
for conditions that
sleep, or for grief reaction.
many will not. Difficulty sleeping tends to be worst in the 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
Some people “cognitive behavioural therapy” – an educational approach that has
• Insomnia onhave other
its own OR symptoms
insomnia where of withdrawal
underlying (e.g. anxiety, irritability,
comorbidities managed • Other sleeping disorders (e.g. restless legs)
andFor
sweating);
those ≥ 65these
yearssymptoms
of age: takingtend to be
BZRA most severe
regardless in the(avoid
of duration first few days
as first been
line therapy shown
in older to help patients
people) stop BZRA. Check out this resource for more
• Unmanaged anxiety, depression, physical or mental
andFor
getthose 18-64
better years
within of age:
a few taking
weeks. If BZRA > 4 weeks
anything odd happens, people should information: http://sleepwellns.ca/.
condition thatYou
maycan also discuss
be causing other options
or aggravating for
insomnia
talk to a health care provider for advice. managing your insomnia if it gets worse when you use a lower dose
• Benzodiazepine effective specifically for anxietyor stop
your BZRA. • Alcohol withdrawal
Engage patients
Reducing or stopping a BZRA may
and reduce daytime sedation and fall risk.
improve
(discuss alertness
potential risks, and thinking
benefits, ability,
withdrawal plan, symptoms and duration)
Personalized BZRA dose reduction strategy:
Other ways toRecommend
manage insomniaDeprescribing Continue BZRA
_____________________________________________________________
• Minimize use of drugs that worsen
For a person who lives in the community: _____________________________________________________________
insomnia (e.g. caffeine, alcohol etc.)
Taper and then stop BZRA
• Go to bed only when sleepy
• Do not use bed or bedroom for anything but sleep (or intimacy)
• Treat underlying condition
_____________________________________________________________
• Consider consulting psychologist or
• (taper
If notslowly
asleepinwithin
collaboration
20-30 with
min patient, for example ~25%
on going/returning every
to bed, exittwo
theweeks, _____________________________________________________________
and if possible, 12.5%
bedroom reductions near psychiatrist or sleep specialist
• end
Useand/or
alarmplanned drug-free
to awaken at thedays)
same time every morning
_____________________________________________________________
• Do not nap
For those ≥ 65 years of age (strong recommendation from systematic review and GRADE approach)
• Avoid caffeine after noon _____________________________________________________________
For exercise,
• Avoid those 18-64 years
nicotine, of and
alcohol, agebig(weak recommendation
meals 2 hours beforefrom systematic review and GRADE approach)
bedtime
_____________________________________________________________
Offer behavioural
For a patient sleepingcare
who lives in long-term advice; consider CBT if available (see reverse)
or hospital:
• Pull up curtains during the day for light exposure If symptoms
This pamphlet accompaniesrelapse:
a deprescribing guideline and
• Keep alarm noises to a minimum algorithm thatConsider
can be used by doctors, nurse practitioners, or
Monitor every 1-2 weeks for duration of tapering
• Increase daytime activity
• Reduce number of naps (no more than 30 minutes and no naps after 2pm)
Use non-drug
approaches to
pharmacists to guide
Maintaining deprescribing.
current BZRA dose for 1-2 weeks, then
continue to taper at slow rate
• Expected
Have warm benefits:
decaf drink, warm milk at night manage
• Restrict
May improvecaffeine,
food, alertness, smoking before
cognition, bedtime
daytime sedation and reduce falls insomnia Alternate drugs
• Use toilet before going to bed Visit have been used to manage
Other medications
Use behavioral
Withdrawal symptoms:
• Have regular bedtime and rising times
Insomnia,
approaches deprescribing.org
insomnia. Assessment of their safety and
• Avoid wakinganxiety,
at nightirritability,
for direct sweating,
care gastrointestinal symptoms and/or CBT effectiveness is beyond the scope of this algorithm.
for more information.
(all
• Try usually gentle
backrub, mild and last for days to a few weeks)
massage (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@bruyere.org or visit deprescribing.org 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)