Module 2: Basic Pharmacology of Controlled Drugs and Substances
Lesson 1
Benzodiazepines – Common indications and dosages
The evidence supporting the use of these agents for managing anxiety is not well-established. First line treatment for anxiety using benzodiazepines is no longer recommended in the Canadian Clinical Practice Guidelines for the Management of Anxiety (CANMAT Anxiety Guidelines 2014). Benzodiazepines have been prescribed for the management of anxiety including panic disorders, insomnia, muscle spasms, control of seizures, and to reduce the symptoms associated with alcohol withdrawal (Edmunds & Mayhew, 2014). Common examples include diazepam, lorazepam, clonazepam, and temazepam.
Prescribers should consider alternatives (e.g. SSRIs, SNRIs, etc.) and limit the use of benzodiazepines to acute/episodic exacerbation of symptoms of anxiety using the CANMAT Guidelines for reference. Dosage should also be individualized and carefully titrated to avoid excessive sedation and mental or motor impairment. The lowest effective dose should be used, and the need for continued therapy reassessed frequently. The risk of dependence may increase with the dose and duration of treatment (Canadian Pharmacists Association, 2014). Use of benzodiazepines in the elderly is controversial. Please refer to Beers Criteria from the American Geriatrics Society to inform your clinical decision making.
Prescribers should also review the Benzodiazepine Equivalency Table in Appendix 6.1 of the Canadian Guideline for the Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (NOUGG, 2017).
| Common Indications, Dosage and Route of Benzodiazepines | ||
|---|---|---|
| Drug | Indication | Usual Oral Adult Dosage |
| Alprazolam* | anxiety | 0.25-0.5 mg PO tid |
| panic disorder | 0.5 mg PO tid | |
| Bromazepam* | anxiety | Initial: 6-18 mg PO/day in divided doses usual maintenance range: 6-30 mg/day |
| Chlordiazepoxide ** | anxiety | 5-25 mg PO tid-qid |
| Clobazam* | seizure disorders | Initial: 5-15 mg/day usually at bedtime maintenance: 20-40 mg /day in 1-2 divided doses |
| Clonazepam* | anxiety, panic disorder | 0.25-0.5 mg bid |
| seizure disorders | Initial: 0.5 mg tid; increase by 0.5-1.0 mg daily every 3 days as needed and tolerated maximum: 20 mg/day |
|
| Clorazepate* | anxiety | 7.5-15 mg bid-qid daily or single dose of 15-22.5 mg HS |
| seizure disorders | Initial: up to 7.5 mg bid-tid; increase by no more than 7.5 mg per week to a maximum of 90 mg/day. | |
| Diazepam** | anxiety/seizure disorders | 2-10 mg bid-qid |
| Flurazepam** | insomnia | 15-30 mg HS |
| Lorazepam* | insomnia | 0.5-1 mg HS |
| Midazolam* | preoperative sedation | 0.25-0.5 mg/kg to a max of 20 mg |
| Nitrazepam* | insomnia | 5-10 mg HS |
| Oxazepam* | anxiety | 10-30 mg tid-qid |
| insomnia | 15 mg 30 to 60 minutes before bedtime | |
| Temazepam* | insomnia | 15 mg HS |
| Triazolam ** | insomnia | 0.125-0.25 mg HS |
* The dose is for younger healthy adults. Doses for elderly patients are approximately one-third to one-half of the recommended adult dose.
** Not recommended in elderly patients.
Reference:
- Canadian Pharmacists Association, 2014; Edmunds & Mayhew, 2014.