HIV Case Conference: Use of Common Benzodiazepines

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1 F/C AETC Faculty Psych Thursday, May 15, :30 1:30pm (EDT) Didactic Presenter Patrick Marsh, MD University of South Florida Facilitator Debbie Cestaro Seifer, MS, RN University of South Florida HIV Case Conference: Use of Common Benzodiazepines Patrick Marsh, MD Faculty, Florida/Caribbean AIDS Education and Training Center (Up to 1.0 hour of CE/CME) 1

2 Learning Objectives Know the mechanism of action of benzodiazepines and some of the potential interactions with other medications Know the typical clinical uses for benzodiazepines Understand the uses and limitations of benzodiazepines in HIV/AIDS population Common Benzodiazepines Rosenbaum

3 Non Benzodiazepine Sedatives Novel Non benzo Zaleplon, Zolpidem, Zoplicone Antidepressants Tricyclics, Trazodone, Mirtazepine, Nefazodone Antihistamines Diphenhydramine, Doxylamine, Hydroxyzine Anticholinergics Scopolamine Supplements Melatonin, Valerian Gamma Aminobutyric Acid (GABA) The chief inhibitory neurotransmitter in the central nervous system Regulates neuronal excitability in the CNS Regulates muscular tone 3

4 Presynaptic Neuron with GABA Reuptake Pump, Vesicles and GABA T Stahl, 2000 GABA receptor with Benzodiazepine Binding Site Stahl,

5 Novel Non Benzo Sleeping Aids Stahl, 2000 Benzo History Dr Leo Henryck Sternbach Chlordiazepoxide (librium) 1956 Diazepam (valium) 1963 Most prescribed drug in USA between Billion doses sold in benzodiazepines available Dellosso

6 Benzo Adverse Effects Intoxication Sedation, impaired learning, psychomotor slowing and anterograde amnesia Cognitive effects Visuospatial, memory Psychomotor effects Traffic accidents, falls, fractures hip fracture risk increase by 50% in the elderly Rebound and tolerance Withdrawal Seizure and death neonate Teratogenicity Cleft palate rarely Dellosso 2013 Benzo Safety Profile High therapeutic window when used alone Dose response curve is very flat at high dose Difficult to cause coma as monotherapy. Dellosso

7 Benzo and Addiction Benzos are less commonly abused as single agent but more commonly abused in combination with other substances. In a patient population for which substance abuse is a serious problem, the use of these drugs for symptomatic relief should be critically examined before prescriptions are given. Benzo and Opiates in 2010 Opioid analgesics were involved in 75% of pharmaceutical overdose deaths Benzodiazepines were also involved in 30% of opioid related deaths Benzodiazepines were in second place, with involvement in 29% of such deaths. King,

8 Indications for Benzodiazepines Alprazolam Anxiety, panic disorder Clonazepam Seizure, panic disorder, periodic leg movement, neuralgia Diazepam Anxiety, sedation, alcohol withdrawal, muscle spasm, seizure, status epilepticus Lorazepam Anxiety, insomnia, status epilepticus, chemo related nausea/vomiting, sedation Physician Desk Reference Benzodiazepines and P450 Robinson

9 Benzodiazepines and Neuroprotection? Lokensgard JR, Chao CC, Gekker G, Hu S, Peterson PK. Benzodiazepines, glia, and HIV 1 neuropathogenesis. Mol Neurobiol Aug;18(1): References Rosenbaum, Jerrold, Handbook of Psychiatric Drug Therapy 5 th Edition, pp 254, Lippincott Williams and Wilkins, 2005 Stahl, Steven M, Essential Psychopharmacology, Neuroscientific Basis and Practical Applications, 2 nd Edition, Cambridge University Press, 2000 Gudin JA, Mogali S, Jones JD Comer SD, Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med.2013 Jul;125(4): Dell osso, B., Lader, M., Do Benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. European Psychiatry, 28 (2013) 7 20 Robinson Michael J., Practical Psychopharmacology in HIV 1 and acquired immunodeficiency syndrome, The Psychiatric Clinics of North America, Mar 2002, (25), 1 King Steven, Benzodiazepines and Pain, Psychiatric Times, May 15,

10 Question & Answer Session 10

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