How Do You Guys Dose Benzos?

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Blitz2006

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So being new to the outpatient world, I've realized/accepted that I obviously need to be an expert on dosing Benzos.

When I have new patients come to me, I see all kinds of regiments. For example, Klonopin 4x/day, or Valium 2x/day.

My basic understanding is:

Xanax = 4x/day (Half Life- 4-6 hours)
Ativan = 3x/day (Half Life - 12-16 hours)
Klonopin = 2x/day (Half Life 32-36 Hours)
Valium = 1x/day (Half Life - 50 Hours)

Am I correct or way off? Is Benzo dosing flexible? I have it my mind that it is pretty rigid, the timing of BZDs in order to make them most efficacious.

Thx,

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Half-life is misleading with benzos. The volume of distribution is much more predictive of the timing of clinical effects - remember that they are lipophilic to varying degrees and so a fair amount of the dose winds up stored in fat where it is not really doing anything to address relevant symptoms (but may be contributing to long term adverse effects).

Strict timing based solely on half life is not going to do what you may be hoping it will do.
 
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Half-life is misleading with benzos. The volume of distribution is much more predictive of the timing of clinical effects - remember that they are lipophilic to varying degrees and so a fair amount of the dose winds up stored in fat where it is not really doing anything to address relevant symptoms (but may be contributing to long term adverse effects).

Strict timing based solely on half life is not going to do what you may be hoping it will do.

Fair enough, I've had attendings drill into me that dosing is based on half-life (for benzos). Thats why I'm here to clarify.
 
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Not a fan of them for long term use generally speaking. I use them frequently inpatient for detox and in the OP setting I tend to do more consolidating and reduction. Keeping in mind the renal, hepatic, addictions hx and geriatric implications my general rules of thumb are:
Xanax-yeah there's that which would be never
Klonopin preference is daily qhs
Valium bid
Ativan tid
 
Not a fan of them for long term use generally speaking. I use them frequently inpatient for detox and in the OP setting I tend to do more consolidating and reduction. Keeping in mind the renal, hepatic, addictions hx and geriatric implications my general rules of thumb are:
Xanax-yeah there's that which would be never
Klonopin preference is daily qhs
Valium bid
Ativan tid

I agree with Xanax. I just want to know these things for academic reasons as well, since I have patients coming in on xanax all the time. I personally avoid prescribing it.
 
It's only under incredibly rare circumstances that I'll have someone on a scheduled benzo. 90% of the time the benzo used is clonazepam. Sometimes Xanax if it's not a medication they're taking every day.

Regarding what they come in on, my goal is reduction so I'll work from where they're at unless they're on an unreasonable dose of something I just say no. Naturally people resist this very much and if they've been on chronic benzos for years then you're just out of luck.

Bottom line is I believe many other factors take a larger priority in dosing than pharmacodynamics.
 
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I've noticed that the ratio of Ativan to Valium in benzo equivalency charts varies between a 1:10 ratio (more common) to 1:5 (seen less often, but in the one @wolfvgang22 linked to).

Not looking for advice but I can tell you that using a 1:10 ratio for me, I found the Valium too potent and I was able to crossover at a lower ratio. I'm a CYP2C19 IM which some data shows increases the potency of one of Valium's main metabolites, desmethyldiazepam.

Also, Valium is generally less potent in Asians than Europeans.

In terms of half life, it can vary in drugs with active metabolites like Valium quite significantly.
 
You are asking the wrong question. Your attendings are idiots. Like all medications, benzodiazepines are dosed by indication, taking into consideration individual differences in the patient, patient preferences, minimizing adverse effects, utilizing placebo effects, positive expectancy and so on. For example you could prescribe lorazepam TID, but it would not be unreasonable to prescribe it BID in a hypomanic or manic patient, or to prescribe it 5x/day in a catatonic patient. Valium would be prescribed qhs for insomnia, but is typically prescribed tid for anxiety, or for the excitement and hyperactivity that occurs when using the MAOIs (particularly parnate), and prescribed qid if scheduled for alcohol withdrawal (and then tapered down). Clonazepam can often be effectively prescribed once a day, particularly if you are using lower doses (such as 0.25 or 0.5mg) for insomnia or nighttime symptoms but it can also carry through the day. Alternatively it could be used BID or even TID.

Xanax is most commonly prescribed TID though xanni bars are asking to be used QID delicious as they. the correct method is never. there is never a reason to prescribe xanax. Alprazolam is not available on the NHS and somehow the UK hasn't fallen apart, but perhaps it would have treated their fears of immigration and prevented Brexit?

As clauswitz mentioned lipophilicity is important - this is why many psychiatrists don't like valium as it tends to cross the blood brain barrier quicker and work more rapidly and is thus more reinforcing than, say, clonazepam. lorazepam takes longer to work and its action is longer than the half-life would suggest. Rate of absorption is also important (diazepam and chlorazepate have a more rapid GI absorption than lorazepam or chlordiazepoxide). To a lesser extent, biotransformation is a factor - oxazepam, temazepam and lorazepam are conjugated rather than oxidized so are no prone to the whims and fancies of liver disease or ageing on drug metabolism.

Although temazepam is usually used for insomnia and thus prescribed qhs, there is no reason why it couldn't be used for other indications and given in divided doses

Also note that even long-half-life benzos have controlled release formulations because the regular ones often require multiple daily dosing (including valium)

Splik's rules for benzo prescription (adapted from George Orwell)

1. never prescribe Xanax
2. never use a short-acting benzo where a long-acting one will do
3. if it is possible to cut a benzo out (or lower the dose), always cut it out
4. never passively continue to prescribe benzos, when you can actively engage the patient in dose reduction and other more effective therapies
5. never prescribe benzos to patient who use DSM phrases, scientific words and jargon to convince you to prescribe them when a patient who was really mentally ill would use everyday English
6. Break any of these rules before doing anything outright barbarous
 
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I think it would depend on the patient, within reason and within evidence based practice guidelines of course.

For example. I am on, what I consider to be, a low dose of Valium. It is dosed 5 mgs BID (10 mgs total), with a granted allowance of some occasional wiggle room of some time limited extra doses here and there if needed, so long as I'm not just chomping my way through an entire bottle with flagrant disregard (I take it for control/relief of muscle spasms; however, I am currently seeking alternate treatments and hoping to taper). This was the dosing protocol deemed most suitable by my GP, who manages my chronic pain conditions, and which has also subsequently been agreed upon by my Psychiatrist.
 
Splik's rules for benzo prescription (adapted from George Orwell)

1. never prescribe Xanax
2. never use a short-acting benzo where a long-acting one will do
3. if it is possible to cut a benzo out (or lower the dose), always cut it out
4. never passively continue to prescribe benzos, when you can actively engage the patient in dose reduction and other more effective therapies
5. never prescribe benzos to patient who use DSM phrases, scientific words and jargon to convince you to prescribe them when a patient who was really mentally ill would use everyday English
6. Break any of these rules before doing anything outright barbarous

I like your rules. :)

Although I do have to say, in response to Number 5 ~ attempted pill seeking by using DSM phrases, scientific words and jargon? Pfft, amateurs! Might as well walk in wearing a shirt with the words 'Drug Seeker' emblazoned across it. :laugh:
 
I like all the rules but 5. I love using the most novel, arcane, historic, medicalized words I can get my hands on, and then even changing the pronunciation around to suit my mood. I do this all the time. Well maybe I take it far enough that I do sound mentally ill come to think of it.
 
You are asking the wrong question. Your attendings are idiots. Like all medications, benzodiazepines are dosed by indication, taking into consideration individual differences in the patient, patient preferences, minimizing adverse effects, utilizing placebo effects, positive expectancy and so on. For example you could prescribe lorazepam TID, but it would not be unreasonable to prescribe it BID in a hypomanic or manic patient, or to prescribe it 5x/day in a catatonic patient. Valium would be prescribed qhs for insomnia, but is typically prescribed tid for anxiety, or for the excitement and hyperactivity that occurs when using the MAOIs (particularly parnate), and prescribed qid if scheduled for alcohol withdrawal (and then tapered down). Clonazepam can often be effectively prescribed once a day, particularly if you are using lower doses (such as 0.25 or 0.5mg) for insomnia or nighttime symptoms but it can also carry through the day. Alternatively it could be used BID or even TID.

Xanax is most commonly prescribed TID though xanni bars are asking to be used QID delicious as they. the correct method is never. there is never a reason to prescribe xanax. Alprazolam is not available on the NHS and somehow the UK hasn't fallen apart, but perhaps it would have treated their fears of immigration and prevented Brexit?

As clauswitz mentioned lipophilicity is important - this is why many psychiatrists don't like valium as it tends to cross the blood brain barrier quicker and work more rapidly and is thus more reinforcing than, say, clonazepam. lorazepam takes longer to work and its action is longer than the half-life would suggest. Rate of absorption is also important (diazepam and chlorazepate have a more rapid GI absorption than lorazepam or chlordiazepoxide). To a lesser extent, biotransformation is a factor - oxazepam, temazepam and lorazepam are conjugated rather than oxidized so are no prone to the whims and fancies of liver disease or ageing on drug metabolism.

Although temazepam is usually used for insomnia and thus prescribed qhs, there is no reason why it couldn't be used for other indications and given in divided doses

Also note that even long-half-life benzos have controlled release formulations because the regular ones often require multiple daily dosing (including valium)

Splik's rules for benzo prescription (adapted from George Orwell)

1. never prescribe Xanax
2. never use a short-acting benzo where a long-acting one will do
3. if it is possible to cut a benzo out (or lower the dose), always cut it out
4. never passively continue to prescribe benzos, when you can actively engage the patient in dose reduction and other more effective therapies
5. never prescribe benzos to patient who use DSM phrases, scientific words and jargon to convince you to prescribe them when a patient who was really mentally ill would use everyday English
6. Break any of these rules before doing anything outright barbarous
Fantastic post, as usual, though I think idiot attendings is a little harsh. I don't always get very detailed regarding benzos initially with students, so maybe the OP's attendings just didn't get a chance to teach as much as they should. I admire Blitz2006 for educating him or herself and fill in the gaps left from training.

Pretty much every psychiatrist I trust follows these same rules you have enumerated.

I note anecdotally that patients rarely ask me for increases in the conjugated benzos, but nearly always ask for escalating doses of diazepam and alprazolam, and to a slightly lesser degree clonazepam. I wish alprazolam would be moved to schedule II. I would rather utilize lorazepam than alprazolam.
 
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The weird thing is that Xanax continues to be the most prescribed psychiatric drug (Ativan is 3rd). The list varies based on year, but Xanax has been first in all I've seen. One doctor told me it's "clean" compared to other benzos. And I know people who have recently been prescribed it for indefinite use. Xanax even got an extended release formulation recently, which I had a doctor try to give me about a year ago. If I were to guess as to its popularity, I would guess that it's due to its relatively (1981) recent introduction compared to other benzos and that each time a new benzo came out there were promises it was less deleterious than previous ones. That "knowledge" dies slowly. Plus it's a lot just the marketing push. If you weed out cheap, workhorse meds, like thyroid hormone, antibiotics, etc., you'll see the most commonly prescribed drugs overall in any year are the ones you've been seeing ads for in the last 3-5 years.
 
When you unveil the damage the brain's main inhibitory system has suffered and the main excitatory system is in overdrive, it could tend to make someone less than pleasant.
 
When you unveil the damage the brain's main inhibitory system has suffered and the main excitatory system is in overdrive, it could tend to make someone less than pleasant.

Among a few other (fairly common) explanations.
 
As an addiction person, I find that people develop pseudo-addiction to benzos and then come to me, and I have a heck of a time trying to wean. There's a lack of access to evidence based psychotherapy for panic disorder and GAD and primary insomnia in the community, and PMDs esp. old PMDs/psychiatrists were trigger happy with going up on benzos. Also, inadequate trials of serotonergic drugs (10mg of Prozac for 2 weeks didn't work for me!) are so prevalent it's almost not worth mentioning. This led to at times need for inpatient detox. I would say try to avoid daily use, and instruct patients to take frequent drug holidays if at all possible. For people who are on regular benzo, inform of the possible risks and if the patient's interested, consider trial of gradual decrease (10% a month or slower). Sometimes it's just impossible to wean, and you have to be okay with that. This is essentially the recommendation in the APA textbook's chapter (Galanter et. al).

FYI, very little scientific evidence for this problem is in existence and it's not a funding priority for research agencies at the moment...so this will have to do for a while...
 
As an addiction person, I find that people develop pseudo-addiction to benzos and then come to me, and I have a heck of a time trying to wean. There's a lack of access to evidence based psychotherapy for panic disorder and GAD and primary insomnia in the community, and PMDs esp. old PMDs/psychiatrists were trigger happy with going up on benzos. Also, inadequate trials of serotonergic drugs (10mg of Prozac for 2 weeks didn't work for me!) are so prevalent it's almost not worth mentioning. This led to at times need for inpatient detox. I would say try to avoid daily use, and instruct patients to take frequent drug holidays if at all possible. For people who are on regular benzo, inform of the possible risks and if the patient's interested, consider trial of gradual decrease (10% a month or slower). Sometimes it's just impossible to wean, and you have to be okay with that. This is essentially the recommendation in the APA textbook's chapter (Galanter et. al).

FYI, very little scientific evidence for this problem is in existence and it's not a funding priority for research agencies at the moment...so this will have to do for a while...
Is it really a lack of access to the treatments? I say this because the docs from the VA report that there is much access to the treatments but a lack of willingness to engage in it. People with addiction are really good at taking a kernel of truth and then using it to justify continued self-destructive behavior. To me it sounds like a variation of "there are no good meetings in this town". "they told me I wasn't sober if I took the meds you prescribed". "there is nothing to do in this town but go to bars". Or the all-time best "you'd drink too if you were married to my spouse".
 
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Google benzodiazepine equivalency chart. I think there is one on UptoDate also.
Actually, here is one.

I was working on editing a text book and was having problems getting reliability between benzo equivalency tables. Can any more seasoned folks chime in?

I was taught 1 Ativan:0.5 Xanax:0.5 Klonapin:5 Valium
I have seen 1 Ativan:0.25 Klonapin as in your link wolf
I have also seen 1 Ativan:10 Valium as mentioned above

Thanks for any help clarifying.
 
Getting other docs out of trouble with their benzo writing habits is a good chunk of our business. It is one of the few examples where maybe we are economically benefiting from the excessive pharma pressure, but in a strangely moral high ground sort of way.

And if I could presume to briefly get on a soap box. Everyone, please stop using Xanax PRN for panic disorder. I have used benzos prn, but not for panic disorders. Panic comes out of the blue (The old Xanax catch phrase from the 80s), although attacks can be triggered, some are not. If 100% of someone’s attacks are triggered, that begins to smell more like a phobia anyway. The track record for benzos in phobias isn’t very good.
 
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And if I could presume to briefly get on a soap box. Everyone, please stop using Xanax PRN for panic disorder. .

Yes please, it would save me the trouble of trying to convince my patients that by the time the xanax kicks in, the panic attack is likely already subsiding, just reinforcing it as a useless safety cue, and putting them at a greater mortality risk if they are elderly. But, they believe that because their psychiatrist/PCP gave them that med for the panic attacks, that I must be the wrong one.
 
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The only patients that seem to be convinced that they should not use benzos as sole treatment for their anxiety are the patients that are actually anxious enough that they worry about the negative effects of long-term use. A sizable percentage of the patients that I have seen who are taking benzos for their "crippling anxiety" show minimal to no visible signs of anxiety. It's not because the medication is working so well either. Much of the time the patient had situational stressors that they were struggling with coping with either because of too many stressors or inadequate coping. The problem is that it is just extremely difficult for any doctor not to prescribe a medication that will help a patient when they come to them with a problem. I can make people feel a little better after the initial visit, but nothing like the immediate relief of a medication.
 
The only patients that seem to be convinced that they should not use benzos as sole treatment for their anxiety are the patients that are actually anxious enough that they worry about the negative effects of long-term use. A sizable percentage of the patients that I have seen who are taking benzos for their "crippling anxiety" show minimal to no visible signs of anxiety. It's not because the medication is working so well either. Much of the time the patient had situational stressors that they were struggling with coping with either because of too many stressors or inadequate coping. The problem is that it is just extremely difficult for any doctor not to prescribe a medication that will help a patient when they come to them with a problem. I can make people feel a little better after the initial visit, but nothing like the immediate relief of a medication.

I agree and why for the very few I have with a true anxiety disorder I often trial a small dose of standing order Klonopin qhs. In my experience the ones this anxious are usually too anxious to actually take a PRN. The patients who are drug seeking, have poor coping skills, low frustration tolerance will eat them like Skittles and for those folks who I tend to inherit from other providers I have absolutely no reservations or problems instituting a taper in conjunction with therapy and usually a SSRI. The ones who want growth and change do surprisingly well and the ones who don't are encouraged to fire me and find a provider who better suits their needs. There are plenty out there who will happily charge for poor prescribing or who don't have the backbone to say no to inappropriate, unsafe regimens in the face of threats, tears, shaking etc.
 
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