De-prescribing benzodiazepine receptor agonists taken for insomnia: a review and key messages from practice guidelines

Abstract

Long -term benzodiazepine receptor agonist (BZRA) use for insomnia is common and highly prevalent in adults in all care settings. Evidence syntheses suggest that the therapeutic benefits of benzodiazepines for insomnia are marginal and very short term. On the harm side, BZRAs are associated with daytime sedation and confusion. Long -term use increases the risk of falls, fractures, cognitive impairment, and motor vehicle accidents. An evidence -based clinical practice guideline has been developed to assist with deprescribing BZRAs. This review highlights the rationale for deprescribing BZRAs used for insomnia and summarizes key messages for clinicians from the new BZRA deprescribing guideline and their supporting evidence.

Why Z-drugs are used even if doctors and nurses feel unable to judge their benefits and risks—a hospital survey

“…This is surprising since a Canadian meta-analysis of risks and benefits of short-term treatment with sedative hypnotics in older people with insomnia concluded already 14 years ago that the benefits of both benzodiazepines and Z-drugs are only marginal and outweighed by the risk of falls or cognitive impairment, particularly in a high-risk elderly population [17]. Later studies confirmed these results, most recently a review from Canada in which Lee and colleagues [18] plea for a strategy of deprescribing benzodiazepines and Z-drugs for insomnia. How, then, did the doctors and nurses in the hospital under study come to their positive risk-benefit assessment of Z-drugs?…”

“…I n a d d i t i o n , pharmacoepidemiological studies report a reduction of benzodiazepine prescribing while Z-drug prescribing is increasing [19]. Z-drugs still seem to benefit from the myth that they are similarly effective and safer alternatives to benzodiazepines, although studies show that Z-drugs also carry the same risks of daytime sedation, cognitive impairment, falls, fractures, and accidents [18].…”

“…Rather, descriptive knowledge about Z-drugs should be accompanied at least by a numerical expression of risks and benefits, similar to a number needed to treat statistic. For example, Lee et al explain that 13 older patients need to be treated with a benzodiazepine or Z-drug for one person to experience improvement in sleep quality, but only 6 patients need to be treated with these drugs for one person to experience an adverse advent [18]. Presenting nurses and doctors with a case series of patients showing these relative frequencies may have similar convincing power as experiential knowledge acquired during practice.…”

Prescrever a desprescrição: uma revisão para um círculo virtuoso

“…O uso prolongado dessas substâncias, mesmo que em dosagens baixas é considerado fator de risco para sonolência, vertigem, cansaço, confusão mental, cefaleia, ansiedade, letargia, amnésia retrógrada, ataxia, hipotensão postural, acidentes, tolerância, dependência e aumento na frequência de quedas. Além de embotamento emocional, ataxia, agressão, nervosismo, sedação e comprometimento cognitivo como perda da atenção, diminuição da aprendizagem verbal e da memória e dificuldades visuomotoras 2,3 .…”

“…Em torno de 50% a 70% dos pacientes fazem uso de BDZ cronicamente, indo de encontro ao tempo de uso recomendado em diferentes publicações a respeito da segurança no uso dessas medicações. Diferentes diretrizes têm recomendado evitar o uso BDZ como agentes de primeira escolha no tratamento da insônia ou até mesmo de prescrevê-los, caso já estejam sendo utilizados atualmente para esse fim 3,5 .…”