Benzodiazepines and related drugs for insomnia in palliative care

 

Abstract

Background

Insomnia, a subjective complaint of poor sleep and associated impairment in daytime function, is a common problem. Currently, benzodiazepines are the most used pharmacological treatment for this complaint. They are considered helpful for occasional short-term use up to four weeks but longer term use is not advised due to potential problems regarding tolerance, dosing escalation, psychological addiction and physical dependence. There is no consensus on their utility in patients with progressive incurable conditions who may require assistance with sleep for many weeks as their condition deteriorates.

Objectives

To assess the effectiveness and safety of benzodiazepines or benzodiazepine receptor agonists such as Zolpidem, Zopiclone and Zaleplon for insomnia in palliative care.

Search strategy

Several electronic databases were searched including Cochrane PaPaS Group specialized register, The Cochrane Library Issue 4, 2001, MEDLINE, EMBASE, BNI plus, CINAHL, BIOLOGICAL ABSTRACTS, PSYCINFO, CANCERLIT, HEALTHSTAR, WEB OF SCIENCE, SIGLE, Dissertation Abstracts, ZETOC and the MetaRegister of ongoing trials. These were searched from 1960 to 2001 or as much of this range as possible.

Selection criteria

Studies considered for inclusion were randomized controlled trials (RCTs) of adult patients in any setting, receiving palliative care or suffering an incurable progressive medical condition. (For example, cancers, AIDS, Motor Neurone Disease, Multiple Sclerosis, Parkinson's Disease, Chronic Obstructive Pulmonary Disease). There had to be an explicit complaint of insomnia in study participants, diagnosed by any of the three main classification systems (DSM-IV (APA 1994), ICSD (AASD 1990) or ICD (WHO 1992), or as described in the study if it involved a subjective complaint of poor sleep. Studies had to compare a benzodiazepine or Zolpidem or Zopiclone or Zaleplon with placebo or active control for the treatment of insomnia. Any duration of therapy were considered.

Data collection and analysis

Abstracts were independently inspected by both review authors, full papers were obtained where necessary. Where there was uncertainty advice was sought by a third review author (PW). Data extraction and quality assessments were undertaken independently by both review authors.

Main results

No RCTs were identified meeting the a priori inclusion criteria. Thirty-seven studies were considered but all were excluded from the review.

Authors' conclusions

Despite a comprehensive search no evidence from RCTs was identified. It was not possible to draw any conclusions regarding the use of benzodiazepines in palliative care.

 

Plain language summary

Benzodiazepines and related drugs for insomnia in palliative care

Still awaiting evidence about whether benzodiazepines used to aid sleep help or hinder patients with incurable diseases. Benzodiazepines are the drugs most often used to aid sleep. Doctors agree that occasional short-term use can be helpful but do not recommend their use for longer than a few weeks for a number of reasons. The drugs may accumulate in the body causing side effects such as daytime drowsiness, tolerance to the drug may develop requiring ever-increasing doses to produce the same sleep-inducing effect and the patient may become physically dependent upon them. There are no guidelines on benzodiazepine use in patients with progressive incurable diseases such as cancer who frequently need help with sleep for several weeks or months as their condition deteriorates. This review carried out a comprehensive search for evidence on the topic but no trials were found.