By: Dr. Raúl López, Psychiatrist
MCS and FHC Collaborator
How to manage the titration and replacement therapy process?
In recent years, complaints of anxiety have frequently surpassed those of depression, obsessiveness and other symptoms in the psychiatry practice and the mental health arena in general. Anxiety is a survival mechanism present in developed species such as primates, mammals and even reptiles when danger is perceived. The brain contains structures such as the amygdala, which promote the secretion of other neurotransmitters that produce an unpleasant sensation such as anxiety.
Since the 1950s, multiple drugs have entered the market to control anxiety. Chlordiazepoxide (lithium), diazepam (Valium®), alprazolam (Xanax®), lorazepam (Ativan®) and others have become popular quick remedies to control anxiety. However, their use and consequences were underestimated by both patients and those who prescribed them.
In recent years, the over-consumption of these drugs for long periods of time has developed tolerance, dependence and sometimes an addiction to the compounds in many patients. Currently, based on long-term research, clinical experiences and the repercussions on the general health of patients, we need to rethink the use of these drugs.
Around 30 million people take benzodiazepines regularly – many in doses not always recommended by their doctors. Therefore, it’s important for physicians to recognize the problem of prescribing benzodiazepine drugs, and consider alternative therapies or even pharmacological strategies such as titration and replacement therapy.
A second step before starting the process is to educate the patient and discuss the physician’s concerns, particularly the risks to the person’s physical and emotional health related to the prolonged use of these therapies. Once an agreement has been reached with the patient, a process to analyze the characteristics and impact of the benzodiazepines should be initiated. Factors such as half-life and excretion route are crucial in designing the titration scale.
In most cases, the process should be carried out over a period of four weeks, starting with a reduction of 25%, with another 25% the second week, and a 12.5% reduction in the subsequent third and fourth weeks, to completely stop the use of the drug. This period may vary from patient to patient, and may take less time. Short-duration benzodiazepines such as alprazolam and lorazepam should be titrated more slowly than long-duration benzodiazepines such as clonazepam and diazepam.
The greatest risk facing this process is the withdrawal syndrome, which occurs around the initial ten days, and varies in intensity from patient to patient. Long-duration benzodiazepines tend to produce fewer withdrawal effects or no physical symptoms. During this process, the use of non-benzodiazepine anxiolytic drugs such as buspirone, mirtazapine and herbals with antihistamine properties can be explored.
While the cessation process for benzodiazepine use lasts an average of four weeks to six months, the psychological process can take years. Non-pharmacological tools such as psychotherapy and lifestyle changes such as meditation, yoga, breathing exercises and others must be implemented to support the titration process, cement long-term anxiety control, and promote complete health.
References:
- Pottie K, Thompson W, Dabvies S, Grenier J, Sadowski C, Welch V, Holbrook A, Boyd C, Swenson JR, Ma A, Farrell B. Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonist. Can Fam Physician 2018; 64:339-51.
- Medscape. 2022. Deprescribing Benzodiazepines: New Primary Care Guidelines Issued. Taken from website:
https://www.medscape.com/viewarticle/896683. Access: January 14, 2022.
