GUIDELINES FOR THE RATIONAL USE OF BENZODIAZEPINES - WHEN AND WHAT TOUSE

The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvuls ant, myorelaxant and amnesic) confer a therapeutic value in a wide ran ge of conditions. Rational use requires consideration of the large dif ferences in potency and elimination rates between different benzodiaze pines, as well as the requirements of individual patients. As hypnotic s, benzodiazepines are mainly indicated for transient or short term in somnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 week s. Temazepam, loprazolam and lormetazepam. which have a medium duratio n of action are suitable. Diazepam is also effective in single or inte rmittent dosage. Potent, short-acting benzodiazepines such as triazola m appear to carry greater risks of adverse effects. As anxiolytics, be nzodiazepines should generally be used in conjunction with other measu res (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action. Indications for benzodiaz epines include acute stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as initial treatment for seven panic and a goraphobia. Diazepam is usually the drug of choice, given in single do ses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and onl y rarely for longer term treatment. Alprazolam has been widely used, p articularly in the US, but is not recommended in the UK, especially fo r long term use. Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses. The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxic ity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects can become major disadva ntages. Unwanted effects can largely be prevented by keeping dosages m inimal and courses short (ideally 4 weeks maximum), and by careful pat ient selection. Long term prescription is occasionally required for ce rtain patients.