Editing Benzodiazepine (section)

==Contraindications==
Benzodiazepines require special precaution if used in the elderly, during pregnancy, in children, [[alcoholism|alcohol]] or drug-dependent individuals and individuals with [[comorbid]] [[psychiatric disorders]].<ref>{{cite journal | vauthors = Authier N, Balayssac D, Sautereau M, Zangarelli A, Courty P, Somogyi AA, Vennat B, Llorca PM, Eschalier A | title = Benzodiazepine dependence: focus on withdrawal syndrome | journal = Annales Pharmaceutiques Françaises | volume = 67 | issue = 6 | pages = 408–413 | date = November 2009 | pmid = 19900604 | doi = 10.1016/j.pharma.2009.07.001 }}</ref>

Because of their muscle relaxant action, benzodiazepines may cause [[hypoventilation|respiratory depression]] in susceptible individuals. For that reason, they are contraindicated in people with [[myasthenia gravis]], [[sleep apnea]], [[bronchitis]], and [[Chronic obstructive pulmonary disease|COPD]].<ref name="isbn0-683-30128-4"/><ref name="isbn0-444-50998-4"/> Caution is required when benzodiazepines are used in people with [[personality disorders]] or [[intellectual disability]] because of frequent [[paradoxical reactions]].<ref name="isbn0-683-30128-4"/><ref name="isbn0-444-50998-4"/> In [[major depressive disorder|major depression]], they may precipitate [[suicide|suicidal tendencies]]<ref>{{cite web |publisher=Committee on Safety of Medicines |year=1988 |url=http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=CON2024428&RevisionSelectionMethod=LatestReleased |format=PDF |title=Benzodiazepines, dependence and withdrawal symptoms |access-date=28 May 2009 |archive-url=https://web.archive.org/web/20120222015417/http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=CON2024428&RevisionSelectionMethod=LatestReleased |archive-date=22 February 2012 |url-status=dead }}</ref> and are sometimes used for suicidal overdoses.<ref name="isbn0-444-50998-4"/> Individuals with a history of excessive alcohol use or non-medical use of [[opioid]]s or [[barbiturate]]s should avoid benzodiazepines, as there is a risk of life-threatening interactions with these drugs.<ref name="isbn1-58829-211-8"/>

===Pregnancy===
{{See also|Long-term effects of benzodiazepines#Neonatal effects|l1=Effects of benzodiazepines on newborns}}

In the United States, the [[Food and Drug Administration (United States)|Food and Drug Administration]] has categorized benzodiazepines into either [[Pregnancy category|category D or X]] meaning potential for harm in the unborn has been demonstrated.<ref>{{cite book |vauthors=Roach SS, Ford SM |title=Introductory Clinical Pharmacology |chapter-url=https://archive.org/details/introductoryclin0000roac |chapter-url-access=registration |edition=8th |year=2006 |publisher=Lippincott Williams & Wilkins |isbn=978-0-7817-7595-3 |page=[https://archive.org/details/introductoryclin0000roac/page/236 236] |chapter=Sedatives and hypnotics }}</ref>

Exposure to benzodiazepines during pregnancy has been associated with a slightly increased (from 0.06 to 0.07%) risk of [[cleft lip and palate|cleft palate]] in newborns, a controversial conclusion as some studies find no association between benzodiazepines and cleft palate. Their use by expectant mothers shortly before the delivery may result in a [[floppy infant syndrome]]. Newborns with this condition tend to have [[hypotonia]], [[hypothermia]], [[lethargy]], and breathing and feeding difficulties.<ref name=ACOG>{{cite journal | title = ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation | journal = Obstetrics and Gynecology | volume = 111 | issue = 4 | pages = 1001–1020 | date = April 2008 | pmid = 18378767 | doi = 10.1097/AOG.0b013e31816fd910 | author1 = ACOG Committee on Practice Bulletins--Obstetrics}}</ref><ref name=pmid9748174>{{cite journal | vauthors = Dolovich LR, Addis A, Vaillancourt JM, Power JD, Koren G, Einarson TR | title = Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies | journal = [[BMJ]] | volume = 317 | issue = 7162 | pages = 839–843 | date = September 1998 | pmid = 9748174 | pmc = 31092 | doi = 10.1136/bmj.317.7162.839 }}</ref> Cases of [[neonatal withdrawal syndrome]] have been described in infants chronically exposed to benzodiazepines [[Uterus|in utero]]. This syndrome may be hard to recognize, as it starts several days after delivery, for example, as late as 21 days for chlordiazepoxide. The symptoms include [[tremor]]s, [[hypertonia]], [[hyperreflexia]], [[hyperactivity]], and vomiting and may last for up to three to six months.<ref name=ACOG/><ref name=pmid9614425>{{cite journal | author = American Academy of Pediatrics Committee on Drugs | title = Neonatal drug withdrawal. American Academy of Pediatrics Committee on Drugs | journal = Pediatrics | volume = 101 | issue = 6 | pages = 1079–1088 | date = June 1998 | doi = 10.1542/peds.101.6.1079 | pmid = 9614425 | url = http://pediatrics.aappublications.org/cgi/reprint/101/6/1079.pdf }}</ref> Tapering down the dose during pregnancy may lessen its severity. If used in pregnancy, those benzodiazepines with a better and longer safety record, such as [[diazepam]] or [[chlordiazepoxide]], are recommended over potentially more harmful benzodiazepines, such as [[temazepam]]<ref>[http://www.rxlist.com/restoril-drug/warnings-precautions.htm Temazepam-Rxlist Pregnancy Category]@</ref> or [[triazolam]]. Using the lowest effective dose for the shortest period of time minimizes the risks to the unborn child.<ref>{{cite journal | vauthors = Iqbal MM, Sobhan T, Ryals T | title = Effects of commonly used benzodiazepines on the fetus, the neonate, and the nursing infant | journal = Psychiatric Services | volume = 53 | issue = 1 | pages = 39–49 | date = January 2002 | pmid = 11773648 | doi = 10.1176/appi.ps.53.1.39 | doi-access = free | title-link = doi }}</ref>

===Elderly===
The benefits of benzodiazepines are least and the risks are greatest in the elderly.<ref name=pmid18035234>{{cite journal | vauthors = Tariq SH, Pulisetty S | title = Pharmacotherapy for insomnia | journal = Clinics in Geriatric Medicine | volume = 24 | issue = 1 | pages = 93–105, vii | date = February 2008 | pmid = 18035234 | doi = 10.1016/j.cger.2007.08.009 }}</ref><ref>{{cite journal | vauthors = Bain KT | title = Management of chronic insomnia in elderly persons | journal = The American Journal of Geriatric Pharmacotherapy | volume = 4 | issue = 2 | pages = 168–192 | date = June 2006 | pmid = 16860264 | doi = 10.1016/j.amjopharm.2006.06.006 }}</ref> They are listed as a potentially inappropriate medication for older adults by the [[American Geriatrics Society]].<ref>{{cite web |title=American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults|url=https://www.guidelinecentral.com/summaries/american-geriatrics-society-2015-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/ |website=Guideline Central |publisher=American Geriatrics Society |access-date=1 December 2018}}</ref> The elderly are at an increased risk of [[drug dependence|dependence]] and are more sensitive to the adverse effects such as memory problems, daytime sedation, impaired motor coordination, and increased risk of motor vehicle accidents and falls,<ref name=pmid16156679>{{cite journal | vauthors = Allain H, Bentué-Ferrer D, Polard E, Akwa Y, Patat A | title = Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review | journal = Drugs & Aging | volume = 22 | issue = 9 | pages = 749–765 | year = 2005 | pmid = 16156679 | doi = 10.2165/00002512-200522090-00004 | s2cid = 9296501 }}</ref> and an increased risk of [[hip fractures]].<ref name="pmid22566242">{{cite journal | vauthors = Khong TP, de Vries F, Goldenberg JS, Klungel OH, Robinson NJ, Ibáñez L, Petri H | title = Potential impact of benzodiazepine use on the rate of hip fractures in five large European countries and the United States | journal = Calcified Tissue International | volume = 91 | issue = 1 | pages = 24–31 | date = July 2012 | pmid = 22566242 | pmc = 3382650 | doi = 10.1007/s00223-012-9603-8 }}</ref> The [[long-term effects of benzodiazepines]] and [[benzodiazepine dependence]] in the elderly can resemble [[dementia]], depression, or [[anxiety syndromes]], and progressively worsens over time. Adverse effects on cognition can be mistaken for the effects of old age. The benefits of withdrawal include improved cognition, alertness, mobility, reduced risk of incontinence, and a reduced risk of falls and fractures. The success of gradual-tapering benzodiazepines is as great in the elderly as in younger people. Benzodiazepines should be prescribed to the elderly only with caution and only for a short period at low doses.<ref name="pmid15001721">{{cite journal | vauthors = Bogunovic OJ, Greenfield SF | title = Practical geriatrics: Use of benzodiazepines among elderly patients | journal = Psychiatric Services | volume = 55 | issue = 3 | pages = 233–235 | date = March 2004 | pmid = 15001721 | doi = 10.1176/appi.ps.55.3.233 }}</ref><ref name="prescribing_for_elderly_patients"/> Short to intermediate-acting benzodiazepines are preferred in the elderly such as [[oxazepam]] and [[temazepam]]. The high potency benzodiazepines [[alprazolam]] and [[triazolam]] and long-acting benzodiazepines are not recommended in the elderly due to increased adverse effects. [[Nonbenzodiazepines]] such as [[zaleplon]] and [[zolpidem]] and low doses of sedating antidepressants are sometimes used as alternatives to benzodiazepines.<ref name="prescribing_for_elderly_patients">{{cite book | vauthors = Jackson SG, Jansen P, Mangoni A | title = Prescribing for Elderly Patients | url = https://books.google.com/books?id=A38nZY3vp2wC | year= 2009 | publisher = Wiley | isbn = 978-0-470-02428-7 | pages = 47–48 }}</ref><ref>{{cite book | vauthors = Rosenthal TC, Williams M, Naughton BJ | title = Office care geriatrics | year = 2006 | publisher = Lippincott Williams Wilkins | location = Philadelphia | url = https://books.google.com/books?id=iyZfvfo-M2wC&pg=PA260 | isbn = 978-0-7817-6196-3 | pages = 260–262 }}</ref>

Long-term use of benzodiazepines is associated with increased risk of cognitive impairment and dementia, and reduction in prescribing levels is likely to reduce dementia risk.<ref name="pmid29926372">{{cite journal |vauthors=Penninkilampi R, Eslick GD |title=A Systematic Review and Meta-Analysis of the Risk of Dementia Associated with Benzodiazepine Use, After Controlling for Protopathic Bias |journal=CNS Drugs |volume= 32|issue= 6|pages= 485–497|date=June 2018 |pmid=29926372 |doi=10.1007/s40263-018-0535-3 |s2cid=49351844 }}</ref> The association of a history of benzodiazepine use and cognitive decline is unclear, with some studies reporting a lower risk of cognitive decline in former users, some finding no association and some indicating an increased risk of cognitive decline.<ref>{{cite journal | vauthors = Verdoux H, Lagnaoui R, Begaud B | title = Is benzodiazepine use a risk factor for cognitive decline and dementia? A literature review of epidemiological studies | journal = Psychological Medicine | volume = 35 | issue = 3 | pages = 307–315 | date = March 2005 | pmid = 15841867 | doi = 10.1017/S0033291704003897 | s2cid = 7774439 }}</ref>

Benzodiazepines are sometimes prescribed to treat behavioral symptoms of dementia. However, like [[antidepressant]]s, they have little evidence of effectiveness, although [[antipsychotic]]s have shown some benefit.<ref>{{cite journal | vauthors = Snowden M, Sato K, Roy-Byrne P | title = Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature | journal = Journal of the American Geriatrics Society | volume = 51 | issue = 9 | pages = 1305–1317 | date = September 2003 | pmid = 12919245 | doi = 10.1046/j.1532-5415.2003.51417.x | s2cid = 2758628 }}</ref><ref>{{cite journal | vauthors = Wang PS, Brookhart MA, Setoguchi S, Patrick AR, Schneeweiss S | title = Psychotropic medication use for behavioral symptoms of dementia | journal = Current Neurology and Neuroscience Reports | volume = 6 | issue = 6 | pages = 490–495 | date = November 2006 | pmid = 17074284 | doi = 10.1007/s11910-006-0051-6 | s2cid = 39610712 }}</ref> Cognitive impairing effects of benzodiazepines that occur frequently in the elderly can also worsen dementia.<ref name="pmid10779253">{{cite journal | vauthors = Longo LP, Johnson B | title = Addiction: Part I. Benzodiazepines – side effects, abuse risk and alternatives | journal = American Family Physician | volume = 61 | issue = 7 | pages = 2121–2128 | date = April 2000 | pmid = 10779253 | url = http://www.aafp.org/afp/20000401/2121.html | access-date = 25 May 2008 | archive-date = 12 May 2008 | archive-url = https://web.archive.org/web/20080512180747/http://www.aafp.org/afp/20000401/2121.html | url-status = dead }}</ref>