Benzodiazepines

Question 1

Phil was recently burgled in his digs. He has become anxious and has been lying awake for much of the night. A 5-day supply of a benzodiazepine hypnotic has been prescribed to help him cope with the insomnia. Which of the following pieces of advice would be appropriate for Phil:

1. Take this medicine for 3–4 days to establish sleep pattern and then stop
2. You must not share this medicine with anybody else and you should store it in a safe place
3. Make sure you read the leaflet that accompanies your medicine, especially the section on how to take your medicine
4. You must complete the course prescribed for you
5. It is alright to drink alcohol socially with this medicine

Choose your answers as follows:

• If 1, 2 and 3 are correct
• If 2 and 4 are correct
• If only 5 is correct
• If 1, 2, 3 and 5 are correct
• If all are correct

Feedback on the responses is given at the end of the module

Question 2

Which of the following statements about benzodiazepine withdrawal effects is true?

• A benzodiazepine with a short half‐life is less likely to provoke withdrawal effects after long‐term treatment
• Withdrawal effects are generally confined to psychiatric features
• It is often necessary to switch to a longer acting benzodiazepine to manage benzodiazepine withdrawal
• If withdrawal effects don’t occur within 36 hours of stopping treatment, it is highly unlikely that they will occur
• Withdrawal effects typically occur only if benzodiazepine treatment lasts longer than several months

Feedback on the responses is given at the end of the module

Question 3

Ali has been taking lorazepam 7.5 mg daily (generally 2.5 mg twice during the day and 2.5 mg at bedtime) for the last 9 months. Ali says that the ‘pills don’t seem to be doing any good but I just can’t seem to cut them out’. Which of the following seem the best options for moving forwards:

1. Ask Ali to try harder (and ‘work through the pain’) to cut out the benzodiazepines
2. Agree a withdrawal plan with Ali, involving a switch to diazepam
3. Ask Ali to cut out the middle dose and just continue on lorazepam 2.5 mg midmorning and 2.5 mg at bedtime
4. Give Ali a leaflet on benzodiazepine withdrawal and involve the family in supporting Ali through the withdrawal effects
5. Substitute the benzodiazepine for another class of anxiolytics

Choose your answers as follows:

• If 1, 2 and 3 are correct
• If 2 and 4 are correct
• If only 5 is correct
• If 1, 2, 3 and 5 are correct
• If all are correct

Feedback on the responses is given at the end of the module

Question 4

Which of the following statements are true?

1. A benzodiazepine usually impairs recall of events that occurred before starting benzodiazepine treatment
2. With prolonged use of a benzodiazepine, the effects on memory are reversed as the sedative effect wears off
3. A CNS stimulant can reverse benzodiazepine-induced memory loss
4. Memory is repaired within about a fortnight of discontinuing a prolonged course of a benzodiazepine
5. A single dose of a benzodiazepine can interfere with recall of events that happen while clinically significant amount remains in the body

Choose your answers as follows:

• If 1, 2 and 3 are correct
• If 2 and 4 are correct
• If only 5 is correct
• If 1, 2, 3 and 5 are correct
• If all are correct

Feedback on the responses is given at the end of the module

Question 5

Sophie takes clonazepam for epilepsy. She has rushed into the late clinic very concerned that her 7-year-old son Louis swallowed the last 2-mg clonazepam tablet from the blister pack soon after he got back from school around 3:30 pm. Louis had his meal before Sophie saw the pack with the missing tablet. It’s now 7:30 pm. Louis is quiet and a little sleepy. His colour is good and his blood pressure, pulse and respiratory rate are unremarkable. What do you do? Choose the single best answer

• Ask Sophie to take Louis to the local accident and emergency department with a note carefully detailing the time of overdose, the medicine, and the amount taken
• Give Louis an age-appropriate dose of activated charcoal and ask Sophie to watch his breathing and colour overnight
• Call an ambulance to transfer Louis immediately to the accident and emergency department with advice to monitor his respiration and ECG while on the way
• Reassure Sophie that she need not worry and can take Louis home, keeping an eye for the next hour or so on his breathing and colour
• Telephone the UK National Poisons Information Service for guidance because poisoning in a child needs to be taken very seriously

Feedback on the responses is given at the end of the module

Question 6

Which of the following can increase the risk of adverse respiratory effects of benzodiazepines?

1. Chronic obstructive pulmonary disease
2. Sleep apnoea
3. Fentanyl transdermal patches
4. Nicotine transdermal patches
5. Beta-lactam allergy

Choose your answers as follows:

• If 1, 2 and 3 are correct
• If 2 and 4 are correct
• If only 5 is correct
• If 1, 2, 3 and 5 are correct
• If all are correct

Feedback on the responses is given at the end of the module

Question 7

Which of the following statements is correct?

• Uncontrolled hypertension is a contraindication to the use of a benzodiazepine
• Intravenous injection of a benzodiazepine should be administered carefully in individuals prone to hypotension and vital signs should be monitored closely
• Co-administration of a benzodiazepine with an antihypertensive, in particular a calcium-channel blocker, should be avoided because of the risk of profound hypotensive effect
• Blood pressure should be monitored for two weeks after initiating benzodiazepine treatment or after increasing the dose
• Torsade de pointes is an important feature of benzodiazepine overdose

Feedback on the responses is given at the end of the module

Question 8

Which of the following circumstances represents appropriate use of a benzodiazepine?

• Intramuscular injection of diazepam 5 mg to relieve a panic attack in a 36-year-old woman
• Diazepam tablet 2 mg the night before a 9.00 am appointment for root-canal work in a 24-year-old man who feels very uncomfortable in the dental chair
• A 4-week course of lorazepam 500 micrograms at night for a 77-year-old woman who lost her husband two days ago
• Oxazepam 15 mg three times daily for a financial professional experiencing difficulty coming to terms with the termination of her employment. She admits to the use of recreational substances ‘most weekends’ to help cope with the demands of her previous job.
• Lormetazepam 1 mg at night in a 56-year-old man whose sleep is disturbed by apnoeic episodes

Feedback on the responses is given at the end of the module

Question 9

Lizzie, a 58-year-old married woman was recently knocked off her bike and sustained a compound fracture to her arm. She takes up to 8 tablets of co-codamol 15/500 daily (in 4 divided doses). Lizzie was prescribed a 2-week course of a benzodiazepine hypnotic to help her sleep at night. However, she now says that she is having awful nightmares and has outbursts over quite trivial matters. What is the best course of action? (Select the single best answer.)

• Switch Lizzie’s analgesic to a NSAID so she is not taking an opioid
• Increase the dose of the hypnotic
• Refer Lizzie to a neurologist in case she has sustained a head injury that was not picked up previously
• Consider discontinuing the benzodiazepine hypnotic
• Reassure Lizzie that these effects are probably due to the trauma and will pass in time

Feedback on the responses is given at the end of the module

Question 10

Which of the following sets of effects are associated with the long-term use of a benzodiazepine:

• Depression, disinhibition, osteoporosis, pathological gambling
• Forgetfulness, hypotension, muscle weakness, parkinsonism
• Depression, ‘emotional anaesthesia’, forgetfulness, inability to concentrate
• Constipation, glaucoma, tardive dyskinesia, tolerance
• Ataxia, convulsions, depression, ECG changes

Feedback on the responses is given at the end of the module

Question 11

Susie, an 82-year-old lady, has been in hospital receiving treatment for community-acquired pneumonia. In hospital, three days before she was discharged, Susie was put on temazepam 10 mg at bedtime to help her sleep in the busy acute ward. On discharge, she brought home a 5-day supply of temazepam, together with some antibiotics. When you see her on the first day back, she is ‘feeling miles better’ except for ‘wooziness’ in the mornings over the last day or two. Beyond encouraging Susie to complete the course of antibiotics, how would you continue her care?

• Switch to diazepam oral solution and reduce the dose by about a tenth or an eighth every 3 days
• Prescribe prochlorperazine to help manage the unsteadiness
• Start reducing the temazepam dose after a couple of days by taking a tablet every other night and then stopping once the supply is finished
• Advise Susie to try not taking any more sleeping tablets and to have a warm milky drink instead
• Advise Susie to continue taking all the pills the hospital has given her but not to get out of bed until late morning when she starts feeling more steady on her feet

Feedback on the responses is given at the end of the module

Question 12

Which of the following statements is correct about benzodiazepine-related withdrawal symptoms?

• Withdrawal symptoms comprise diarrhoea, runny nose, flu-like symptoms, myalgia
• Individuals develop excessive drowsiness
• Neuropsychiatric symptoms comprise sensory and perceptual distortion, and psychosis
• Individuals develop hypotension and reflex tachycardia
• Withdrawal effects reach their peak within two days of stopping a benzodiazepine

Feedback on the responses is given at the end of the module