Drugs used in status epilepticus 261 Driving Hypnotics and anxiolytics may impair judge-
4.8.2 Drugs used in status epilepticus 261 Driving Hypnotics and anxiolytics may impair judge-
4.8.3 Febrile convulsions
ment and increase reaction time, and so affect ability to
4.9 drive or operate machinery; they increase the effects of Drugs used in parkinsonism and
alcohol. Moreover the hangover effects of a night dose
related disorders
264 may impair driving on the following day. See also Drugs
4.9.1 Dopaminergic drugs used in and Driving under General Guidance, p. 3. parkinsonism
Dependence and withdrawal 4.9.2 Withdrawal of a ben-
Antimuscarinic drugs used in
parkinsonism zodiazepine should be gradual because abrupt with-
drawal may produce confusion, toxic psychosis, con- vulsions, or a condition resembling delirium tremens.
4.1.1 Hypnotics BNF 57 Abrupt withdrawal of a barbiturate (section 4.1.3) is
Transient insomnia may occur in those who normally even more likely to have serious effects.
sleep well and may be due to extraneous factors such as The benzodiazepine withdrawal syndrome may develop
noise, shift work, and jet lag. If a hypnotic is indicated at any time up to 3 weeks after stopping a long-acting
one that is rapidly eliminated should be chosen, and benzodiazepine, but may occur within a day in the case
only one or two doses should be given. of a short-acting one. It is characterised by insomnia,
Short-term insomnia is usually related to an emotional anxiety, loss of appetite and of body-weight, tremor,
problem or serious medical illness. It may last for a few perspiration, tinnitus, and perceptual disturbances.
weeks and may recur; a hypnotic can be useful but Some symptoms may be similar to the original com-
should not be given for more than three weeks (pre- plaint and encourage further prescribing; some symp-
ferably only one week). Intermittent use is desirable toms may continue for weeks or months after stopping
with omission of some doses. A rapidly eliminated benzodiazepines.
drug is generally appropriate.
A benzodiazepine can be withdrawn in steps of about Chronic insomnia is rarely benefited by hypnotics and is one-eighth (range one-tenth to one-quarter) of the daily
sometimes due to mild dependence caused by injudi- dose every fortnight. A suggested withdrawal protocol
cious prescribing of hypnotics. Psychiatric disorders for patients who have difficulty is as follows:
such as anxiety, depression, and abuse of drugs and
1. Transfer patient to equivalent daily dose of dia- alcohol are common causes. Sleep disturbance is very zepam 1 preferably taken at night
common in depressive illness and early wakening is tem often a useful pointer. The underlying psychiatric com- 2. Reduce diazepam dose every 2–3 weeks in steps of
2 or 2.5 mg; if withdrawal symptoms occur, main- plaint should be treated, adapting the drug regimen to
sys
tain this dose until symptoms improve alleviate insomnia. For example, clomipramine or mir- tazapine prescribed for depression will also help to
3. Reduce dose further, if necessary in smaller steps; 2 promote sleep if taken at night. Other causes of insom- it is better to reduce too slowly rather than too
nia include daytime cat-napping and physical causes
nervous
l such as pain, pruritus, and dyspnoea.
quickly
4. Stop completely; time needed for withdrawal can Hypnotics should not be prescribed indiscriminately vary from about 4 weeks to a year or more
C entra Counselling may help; beta-blockers should only be reserved for short courses in the acutely distressed. tried if other measures fail; antidepressants should be
and routine prescribing is undesirable. They should be
4 Tolerance to their effects develops within 3 to 14 days
used only where depression or panic disorder co-exist of continuous use and long-term efficacy cannot be or emerge; avoid antipsychotics (which may aggravate
assured. A major drawback of long-term use is that withdrawal symptoms).
withdrawal can cause rebound insomnia and a with- drawal syndrome (section 4.1).