Hospitalist Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 03, 2018

In This Article

Deprescribing Benzodiazepines for Insomnia

Canadian Guideline Development Team

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

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.

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, but data show such harms are often overlooked, especially in older patients.

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. 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.

Clinicians should 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).

Consider using behavior management strategies to help patients with insomnia.

Deprescribing BZRAs can include the following:

  • Abruptly stopping the BZRA (ie, abrupt discontinuation)

  • Tapering the BZRA dose (ie, gradually reducing the dose until complete cessation of the BZRA)

  • Recommending CBT (ie, a CBT program for insomnia with the aim of stopping or reducing BZRA use in the process)

  • Combining tapering and CBT

  • Reducing BZRA use with the following approaches: using a lower dose of BZRA compared with baseline; using BZRAs only as needed

  • Providing substitutive therapy (ie, discontinuing the BZRA and replacing it with an alternative agent [eg, melatonin] either abruptly or by cross-tapering)

For elderly adults (≥65 y) who use BZRAs, it is recommended to taper the BZRA dose slowly.

For adults (18 to 64 y) who have used BZRAs most days of the week for >4 weeks, it is recommended to taper the BZRA dose slowly.



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