Usages et bon usage des benzodiazépines anxiolytiques et hypnotiques

Abstract

Since 60 years, benzodiazepines have replaced barbiturates and are now the most prescribed anxiolytic and hypnotic drugs at the international level. France is one of the largest users of benzodiazepines in the world, with more than 13% of its population exposed to this pharmacological class. At the European level, France is in 2nd place just behind Spain. Benzodiazepine use has spread for the management of sleep disorders and anxiety, because of their effectiveness and their relative safety in case of acute intoxication, compared to previous drugs. Epidemiology data show that benzodiazepine use increases with age, and reaches a peak in the elderly. Benzodiazepine use is more common in women (with a ratio of 2 women for one man of the same age). The co-prescription of 2 benzodiazepines at the same time is found in 1 user in 5. Some prescriptions do not comply with the regulations in force, in terms of duration of treatment (15%), dosage and therapeutic indication. However, the evidence of their effectiveness is limited to the legal duration of their prescription, with a risk of reversing the balance of benefits and risks in the instance of prolonged use. The main undesirable effects are due to depressive effects on the central nervous system, and consist of drowsiness, falls, or orthostatic hypotension, which occur during prolonged use, including substance use disorders. Moreover, prolonged use can lead to the occurrence of a withdrawal syndrome, as well as cognitive disorders. In the context of epidemiological overconsumption, this review aims to synthesize the evidence on the risk/benefit ratio of these molecules in their most common indications. Moreover, this article also provides practical rules of good practice, which include in an objective of overall patient care before prescribing anxiolytic or hypnotic benzodiazepines, the reminder of non-medicinal measures such as those of lifestyle, psychotherapy and, if necessary, the use of alternative medicines. If a prescription is initiated, it will then be necessary to choose the minimum effective dosage, the minimum effective duration of treatment, and the molecule which fits the most with recommendations. Finally, deprescribing, a too-often forgotten phase of treatment, allows for a controlled cessation of treatment. Deprescribing should be performed gradually and after evaluation of the patient's degree of pharmacological dependence and of his expectations and motivations. Planned deprescribing also finds its place from the initiation of a treatment, on the basis of a therapeutic alliance with the patient, informed therefore of the benefits and risks of his treatment, and therefore of the resulting modalities such as its limited duration. comprising a decrease in doses until discontinuation. The pharmacist and the prescribing physician are two guarantors of the correct use of benzodiazepines and related drugs. They must work in a coordinated manner and have a common discourse with patients to explain to them, during their initiation, the transient benefits, risks and alternatives to these treatments. These professionals must also support patients in the deprescribing phase, a phase which is too-often overlooked in situations of chronic prescribing.