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4.1 Hypnotics and anxiolytics

Drugs and driving – MHRA Drug Safety Update Feb 2015

It is against the law to drive if your driving ability is impaired by any medicine. It is also an offence to drive with certain drugs above specified levels in the body, whether your driving is impaired or not – for further information, click here
         

4.1.1 Hypnotics

 The National Institute for Health and Care Excellence (NICE) TA77 recommends hypnotics to be prescribed for up to two weeks only, after non-drug measures have failed and the patient’s insomnia is severe, disabling or causing the patient extreme distress.  This is due to concerns over hypnotic dependence.

Recommendations:

  • For new patients, offer non-drug measures such as a ‘good sleep hygiene guide’ before prescribing medication. Identify and treat underlying causes 
  • Benzodiazepines and the Z–drugs (zopiclone and zolpidem) should be avoided in the elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury  
  • Should a prescription be considered appropriate (non-drug measures have failed and the patient’s insomnia is severe, disabling or causing extreme distress), use a benzodiazepine or Z-drug at the lowest dose and for up to two weeks only.  
  • Do not routinely add hypnotics to repeat prescribing systems. 
  • As there is little to choose between short acting benzodiazepines and Z-drugs, choose a hypnotic with the lowest acquisition cost. Currently, generic zopiclone 7.5mg tablets are the lowest cost hypnotic. Avoid long acting hypnotics, e.g. nitrazepam due to increased risk of residual effects the following day 
  • If a patient does not respond to one Z-drug, do not switch to another hypnotic in an attempt to get a response as there is no evidence to suggest that switching works. 
  • For chronic hypnotic users, review their need for a hypnotic and offer them support to withdraw from their hypnotic. 
  • •Implement practice policy in line with above recommendations, considering patient contracts as appropriate. Practice policies include management of “out of hours” and emergency patient requests.
  • Review prescribing of hypnotics for patients discharged from secondary care. 
  • Collaborate with substance misuse services, community mental health teams and voluntary agencies if necessary. 

Further guidance on appropriate and cost-effective prescribing of short acting hypnotics is available.

Zopiclone tablets - see notes. First line choice. See NICE TA 77.
Temazepam tablets, oral solution (requires ordering in CD book) - Click here for change to prescription requirements
Nitrazepam tablets Chloral hydrate mixture (paediatrics only - for sedation prior to diagnostic procedures only)

Promethazine tablets, elixir
Melatonin (M/R tablets, Circadin) - for sleep disturbances in children and adolescents with visual problems, learning difficulties, cerebral palsy and autistic spectrum disorders – unlicensed indication - specialist use only - see note, PrescQIPP review, and guideline.

Notes:

1. In Derbyshire, Circadin® 2mg MR tablets (off-label) is the 1st line choice of melatonin for new patients for the treatment of sleep disorders initiated by a specialist in children with neurodevelopment disorders. See guideline for advice on administration to children with swallowing difficulties. 

 

 4.1.2 Anxiolytics

Diazepam tablets, syrup, emulsion injection, rectal tubes, suppositories
Chlordiazepoxide capsules – alcohol withdrawal only - see note
Propranolol tablets, syrup                    
Promazine tablets, oral solution, injection
Lorazepam tablets, injection - see agitation guidelines. See notes.
Midazolam injection
 

Notes:

1. Chlordiazepoxide is associated with low dependence and therefore low withdrawal symptoms and is particularly useful for alcohol withdrawal. See Alcohol Withdrawal guidelines.

2. Midazolam is used in paediatrics via unlicensed routes (oral, buccal or intra-nasal) for sedation prior to procedures and for status epilepticus. Click here for shared care.

3. Propranolol is indicated if somatic symptoms predominate

4. Benzodiazepines are indicated for the short-term relief (2-4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness. The use of benzodiazepines to treat short-term 'mild' anxiety is inappropriate.

For link to BNF section: 4.1 Hypnotics and anxiolytics