Benzodiazepines (commonly known as "tranquillisers"

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

Benzodiazepines are also referred to as tranquillisers and are drugs mainly prescribed for anxiety and insomnia. They are occasionally prescribed for epilepsy, as muscle relaxants, and as a detox from alcohol. They should only be prescribed short term as they can have serious side effects, withdrawal symptoms and addiction problems if overused. They should only be used short-term for the likes of anxiety until the effects of longer term treatment options (eg. counselling, antidepressants, mood stabiliser medication) start working. Benzodiazepines have been prescribed in Ireland for over 50 years and there has been a long history of overprescribing. When they first came out, the likes of “valium” were seen as wonder drugs, their potential problems and side effects were not realised initially and “mother’s little helpers” were overprescribed by family doctors. Only in the last few years have efforts been made to reduce over and inappropriate prescribing.

How they work?

Benzodiazepines work by slowing the communication between neurons giving a calming effect to many functions of the brain. Benzodiazepines main effect is to reduce anxiety and agitation, while it does this quickly (within half an hour); this effect is short lived (a few hours only). Side effects can include drowsiness and slowing of mental and bodily movements.

Benzodiazepines may cause confusion, slurred speech, coordination problems, impairment of judgement and memory loss in some people, especially at higher doses. Paradoxically they can cause mood swings in some people (perhaps this is more when the dose wears off).  With long term use, tolerance can occur; this involves needing higher doses to produce the same effects. Dependence can also occur with longer term use (more than a week); symptoms can include feeling a constant need for the drug with the feeling of not being able to function right without it and developing withdrawal symptoms if the drug is stopped. Withdrawal symptoms can be debilitating and can include nausea, vomiting, sweats, low mood, and paranoia and panic attacks.

 Benzodiazepines combined with alcohol or other medication (even some common over the counter medicines such as pain-killers and anti-histamines) can cause loss of consciousness and respiratory failure. Side effects are rare if doses are kept low and courses are short (ideally 4 weeks maximum).

Types of benzodiazepine

Examples of benzodiazepine include include alprazolam (Xanax^®), clonazepam (Rivotril^®), lorazepam (Ativan^®), diazepam (Valium^®, Anxicalm^®), and chlordiazepoxide (Librium^®). Some benzodiazepines have a very sedative effect so are only used as sleeping tablets; these include triazolam (Halcion^®), nitrazepam (Mogadon^®), temazepam (Nortem) and flurazepam (Dalmane). They should only be used short term as sedatives due to the reasons like tolerance, dependence and withdrawal symptoms described earlier.  

Use in the elderly

In older people, benzodiazepines are associated with more severe side effects including marked sedation and psychomotor impairment (slowdown of mental and physical activity), higher risk of fractures (especially hip fractures) and driving accidents, and a quicker development of tolerance, dependence and withdrawal symptoms (when compared to younger patients). Their use in the elderly should be avoided but if they are used they should be used with caution.

This article is shortened for this Health Blog.. More detailed information and leaflets is available in Whelehans or check www.whelehans.ie

Kidney-Transplant patients- What Over-the-Counter (OTC) medication can you take?

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

Organ Donor Awareness Week is this week (March 29^th to April 5^th). Give the gift of life by getting an organ donor card from the Irish Kidney Association on LoCall 1890 543639 or logon to www.ika.ie. While I specifically deal with kidney transplants this week, much of the advice I give is true for any type of transplant (eg) Heart, lung, liver. Kidney failure has many causes including diabetes, high blood pressure and injury. Kidney failure causes a build-up of waste products and fluids leading to tiredness and fatigue, oedema (swelling), nausea and poor appetite and even death if a suitable donor is not found.

Medication to avoid

When you have a kidney transplant, medication called immunosuppressants are prescribed to prevent the body rejecting the new kidney. Some medications interfere with the immunosuppressive medications. Antibiotics to avoid include clarithromycin (Klacid^®), erythromycin and azithromycin (Zithromax^®). Other drugs to avoid include the antifungal fluconazole (Diflucan^®) and the heart rhythm drug diltiazem (Dilzem^®).

AVOID grapefruit or grapefruit juice when prescribed immunosuppressants like Neoral^®, Prograf^® or Rapamune^®; grapefruit changes the metabolism of these medications. Avoid antacids such as Rennies^®, Maalox^® or Gaviscon^® within 2 hours of taking your medications as they may reduce absorption of many anti-rejection drugs.

Herbal preparations and supplements

Herbs can cause serious interactions with kidney transplant drugs and can also affect the kidneys. *Some herbs reduce the effectiveness of transplant rejection medication. *Herbs may not be pure because of unregulated manufacture procedures. There have been reports of herbs containing bacteria, pesticides and metals including lead and mercury. *Some herbs are toxic effects to the liver, kidneys, and heart, especially when taken with other medication including changes in blood pressure, blood sugar and potassium levels leading to risk of bleeding and transplant rejection. *Dosages can vary from pill to pill, manufacturer to manufacturer or from what is stated on the label. To be safe, transplant patients should avoid herbal preparations.

What Over the Counter Medication is safe?

Headache, Fever, and Body Aches

Paracetamol eases mild pain and fever and is safe for kidney transplant patients (but use in caution if you had a liver transplant). Non-steroidal anti-inflammatory drugs (NSAIDs) must be avoided as they can harm the kidneys and interact with some immunosuppressants. Ibuprofen (Nurofen^®) is a common NSAID sold over the counter. Aspirin is a relation of NSAIDs so should also be avoided unless prescribed for medical reasons (eg) low dose aspirin to prevent clots

Sneezing, Itching and Runny Nose
Antihistamines can be safely used by transplant patients. Loratadine (Clarityn^®) and cetirizine (Zirtek^®) are recommended as they cause less drowsiness than other anti-histamines. Chlorpheniramine (Piriton^®) is also safe to use but is best used at bedtime as it causes more drowsiness. Avoid combination (multi-symptom) cold, sinus, and flu products (Benilyn Day & Night^®, Benylin 4Flu^®, Nurofen Cold and Flu^®). Treat each symptom individually to avoid accidentally taking a drug that can cause kidney problems.

Sore Throat

Most throat lozenges (eg. Strepsils^®) are safe to use and there are sugar free versions for diabetics.

Nasal and Sinus Congestion

Nasal sprays such as xylometazoline (Otrivine^® and Sudofed^®) are safest for congestion problems. Do not use longer than three days as longer use can make congestion worse. Salt sprays (eg. Sterimer^®) as nasal washes (eg. Neilmed Sinus Wash^®) can ease sinus systems by moistening sinuses and acting as a natural anti-inflammatory and are safe to use long term.  Oral decongestants, such as pseudoephedrine (contained in the likes of Sudafed^® tablets and many cold and flu remedies) should be used with care for transplant patients as they raise blood pressure which can put pressure on kidneys.

Chesty Cough

Guaifenesin (Robitussin^®, Viscolex^® or Exputex^®) is safe for transplant patients suffering from chest congestion.

Dry Cough

The cough suppressant dextromethorphan (Benilyn^® Dry Cough) is safe to use. Vicks VapoRub^® can help relieve a cough for a time. If diabetic, use a sugar free version such as Robitussin^® Dry Cough Mixture.

Diarrhoea

Loperamide (Imodium^®) can be used for short-term relief of diarrhoea. Do not use for longer than 48 hours. If diarrhoea is heavy, bloody, or lasts more than 48 hours, get checked by a doctor.

Constipation

Products safe to use for transplant patients include fibre supplements (Fybogel^®); stimulants such as bisacodyl (Dulcolax^®) or senna (Senokot^®) and osmotic laxatives such as lactulose (Duphalac^®). Do not use stimulant laxatives such as bisacodyl or senna long term as they cause lazy bowel which can worsen constipation. If constipation last longer than 48 hours you should see your doctor.

Indigestion and heartburn

Mild stomach upset can be eased with some over the counter remedies such as antacids (eg) Rennies^®; famotidine (Pepcid AC^®) and pantoprazole (Pantup Relief^®). Avoid antacids at the same time as immunosuppressants such as mycophenolate (Cellcept^®), tacrolimus (Prograf^®) or sirolimus (Rapamune^®) as they reduce absorption of these drugs. Take OTC remedies such as antacids at least one hour before or two hours after the immunosuppressant

Gas

Simethicone (Imogas^®) is recommended for gas which is a common cause of bloating.

Dry Eyes and Eye Irritation

Artificial tears eye drops should be first choice for the symptoms of dry eyes and eye irritation. They replicate the role of natural tears. Examples include Tears Naturale^® and Artelac Drops^®.

Nausea and Vomiting
Domperidone (Motilium^®, Domerid^®) can be used to treat and prevent symptoms of nausea and vomiting but only be use short term. See your doctor if nausea and vomiting lasts more than 24 hours as it can be caused by your prescription medication.

Skin Irritation, Insect Bites and Poison Ivy

Topical corticosteroids, such as hydrocortisone 1% cream (Cortisol 1% Cream), is safe to use for skin irritation, insect bites, and skin rashes. Use of corticosteroids should be short term (no longer than 7 days) as they can thin and mark the skin if used long term.

Disclaimer: Consult with your healthcare professional before making any changes recommended.

This article is shortened for my health blog. More detailed information and leaflets is available in Whelehans