BENZODIAZEPINES IN HOSPICE
We’ve noticed an upward trend upon evaluating medications during medication profile reviews. I would like to send out a reminder of the maximum dosing frequencies and maximum dosages of the most frequently used benzodiazepines.
When ORAL benzodiazepines exceed either the maximum daily dose or dosing frequency for symptoms of anxiety, aggression, and/or agitation, it can cause a paradoxical reaction. This manifests with symptoms of anxiety and hyperactive or aggressive behavior. The risk may be increased in geriatric patients, patients with a history of an alcohol-use disorder, or psychiatric/personality disorders. Essentially, the symptoms that benzodiazepines treat can cause those same symptoms when doses and/or dosing frequencies are too high.
Also on the radar are the following:
Benzodiazepines have been associated with anterograde amnesia.
Use with caution in patients with respiratory disease, including COPD or sleep apnea. Benzodiazepines may cause significant respiratory depression.
Use with extreme caution in patients who are at risk of falls; benzodiazepines have been associated with falls and traumatic injury.
Use with caution in debilitated patients; initial doses should be at the lower end of the dosing range.
Below are the most commonly used benzodiazepines and their maximum dosing for palliative care and hospice:
Lorazepam:
Advanced cancer and/or palliative care/hospice
Maximim Dose: 0.25 to 2 mg every 3 to 6 hours as needed with a maximum daily dose of 16mg.
Note: The tablet and oral solution may be administered sublingually at the same doses when other routes are unavailable.
Alprazolam:
Maximum daily dose is 10mg
Initial dosage:
0.25 mg 3 to 4 times daily.
Dosage titration
May increase dose based on response and tolerability in increments ≤1 mg/day at intervals ≥3 days up to a usual dose of 2 to 6 mg/day in 3 to 4 divided doses. Some patients may require up to 8 mg/day for optimal response. With doses >4 mg/day, increase more gradually to minimize adverse effects; periodically reassess and consider dosage reduction.
Dosage: Geriatric
Immediate release:
Use lower initial doses of 0.25 mg 2 to 3 times daily and titrate slowly; refer to adult dosing.
Clonazepam:
Note: Reduce dose or avoid use in patients receiving opioids, with significant chronic disease (eg, respiratory compromise), or at increased risk for accumulation (eg, hepatic impairment). Generally, avoid use in patients with, or at risk for, substance use disorders; if prescribed, closely supervise use.
Anxiety disorder (adjunctive therapy or monotherapy) (alternative agent)
Note: While FDA-approved for panic disorder, clinical trials also support use in other anxiety disorders. Generally used short-term for symptom relief until concurrent therapy is effective (eg, ≤12 weeks). Long-term, low-dose therapy may be used for select patients when other treatments are ineffective or poorly tolerated. Use with caution in patients with posttraumatic stress disorder; benzodiazepines may worsen symptoms.
Maximum dosage
4 mg/day in 1 to 4 divided doses.
Initial dosage
0.25 to 1 mg/day in 1 to 2 divided doses; may be given as needed or scheduled.
Dosage titration
If needed, may increase the daily dose based on response and tolerability in increments of 0.25 to 0.5 mg every few days (eg, ≥3 days); usual target range: 1 to 3 mg/day. To minimize daytime motor impairment and drowsiness, it may be taken as a single dose at bedtime.
Diazepam:
Anxiety, acute/severe (monotherapy or adjunctive therapy):
2 to 10 mg every 3 to 6 hours as needed up to 40 mg/day; adjust dose based on response and tolerability.
Anxiety disorders (monotherapy or adjunctive therapy) (alternative agent):
Note: Most commonly used short-term for immediate symptom relief until concurrent therapy is effective (eg, ≤12 weeks). Long-term therapy may be considered for select patients only when other treatments are ineffective or poorly tolerated.
2 to 5 mg once or twice daily initially; increase gradually based on response and tolerability up to 40 mg/day in 2 to 4 divided doses.
As a final note, please remember that all benzodiazepines need to be tapered when discontinuing!
Please feel free to reach out to our clinical staff if you have any concerns or questions regarding benzodiazepine therapies.
PDC Clinical Team