Long-term risk of hip or forearm fractures in older occasional users of benzodiazepines

Sedative-hypnotics and osteoporotic fractures: A systematic review of observational studies with over six million individuals

We reviewed and meta-analyzed 20 observational studies to examine the relationship between sedative-hypnotic use and osteoporotic fractures. We searched PubMed, Embase, APA PsycINFO, and Web of Science™ for studies that used cohort, case-control, case-crossover, and self-controlled case series designs. We further assessed the quality of each study and performed meta-analyses of association estimates, e.g., odds ratios (ORs). The analysis included 6,084,083 participants and found a slight association between the use of sedative-hypnotics and osteoporotic fractures, with differing strength of associations between different classes of drugs and greater sedative-hypnotics exposure. The pooled estimates ORs for case-control studies were 1.33 (95% CI 0.98-1.80) with benzodiazepines (BZD) and any fractures, 1.32 (95% CI 1.05-1.66) with BZDs and hip fractures, and case-crossover studies were 1.15 (95% CI 0.95-1.41) with BZDs and any fractures, 1.41 (95% CI 1.08-1.85) with Z-drugs and any fractures. The study suggests that more research is needed to aid medical professionals in balancing this potential risk of osteoporotic fractures associated with sedative-hypnotic use against other reported adverse events and anticipated therapy outcomes.

Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on fall risk associated with benzodiazepines (BZDs) and Z-drugs in older people with focus on appropriate prescribing, including deprescribing.

METHODS

We conducted a literature search in June 2021 in PubMed and Embase with citation and reference checking. Personal reference libraries and international websites were also used. Keywords for the searches included "benzodiazepines", "Z-drugs", "falls", "deprescribing", "fall-risk-increasing-drugs", "inappropriate prescribing", "older people" and matching synonyms. We discuss use of BZDs and Z-drugs, potential fall-related adverse reactions, alternatives for and deprescribing of BZDs and Z-drugs in older persons.

RESULTS

BZDs and Z-drugs differ in fall-related adverse effect profile. They contribute to fall risk through orthostatic hypotension, dizziness and/or imbalance, sedation, muscular weakness, ataxia, etc. Fall incidents contribute significantly to mortality and morbidity. Therefore, there is a need for appropriate prescribing and use of BZDs and Z-drugs in older people. In practice, this means pertaining to a strict indication, strongly consider to non-pharmacological alternatives, limit use to the lowest dose and the shortest duration possible. Judicious deprescribing should be considered and encouraged as well. Practical resources, tools and algorithms are available to guide and assist clinicians in deprescribing BZDs and Z-drugs.

CONCLUSIONS

Prescribing BZDs and Z-drugs should be done in a well-considered way in fall-prone older people. A good overview and insight in the fall-related adverse effects of these drugs, as well as the availability of different strategies to increase the appropriate use, including deprescribing initiatives, can assist clinicians in clinical decision-making.

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

Long-term benzodiazepines and z-drug prescribing in Australian general practice between 2011 and 2018: A national study

Despite reducing benzodiazepine prescribing, benzodiazepine-involving deaths have substantially increased in Australia. This study aimed to explore patterns in long-term prescribing of medications (benzodiazepine and z-drugs [BZD]) used for sleep-issues/insomnia in Australia to better understand these changes. Open cohort study using de-identified electronic health records of 1 414 593 adult patients regularly attending 404 Australian general practices from 2011 to 2018 (MedicineInsight). We used logistic regression adjusted for patient and practice characteristics to; (1) estimate long-term BZD prescribing prevalence (≥3 prescriptions in 6 months) and the associated sociodemographic factors, and (2) Poisson regression to compute annual changes in prescribing rates. Long-term BZD prescribing changed from 4.4% in 2011 to 5.8% in 2015, remaining relatively stable until 2018 (annual increase +2.5% [95% CI +2.0%;+3.0%]). Long-term BZD prescribing in any year was up to six times more likely in elderly rather than in younger patients and 30%-43% more prevalent in females, or patients living in or attending a practice located in more disadvantaged areas. The increase was more pronounced among males, adults aged 35-49 years, and individuals living in advantaged areas. The median duration among incident cases decreased from 1183 to 322 days between 2011 and 2017, and was up to 197 days longer among elderly females than males. Despite a slight increase and recent stability in long-term BZD prescribing, the higher rates and durations among elderly patients, women, or those living in more disadvantaged areas are concerning and highlights the need for interventions that reduce the potential harms of long-term BZD use in vulnerable groups.

Long-term risk of hip or forearm fractures in older occasional users of benzodiazepines

AIMS

This article sought to study the association between patterns of benzodiazepine (BZD) use and the risk of hip and forearm fractures in people aged 50 and 75 years or more.

METHODS

In a representative cohort of the French National Health Insurance Fund of individuals aged 50 years or older (n = 106 437), we followed up BZD dispensing (reflecting their patterns of use) and the most frequent fall-related fractures (hip and forearm) for 8 years. We used joint latent class models to simultaneously identify BZD dispensing trajectories and the risk of fractures in the entire cohort and in those 75 years or older). We used a survival model to estimate the adjusted hazard ratios (aHRs) between these trajectories and the risk of fractures.

RESULTS

In the entire cohort, we identified 5 BZD trajectories: non-users (76.7% of the cohort); occasional users (15.2%); decreasing users (2.6%); late increasing users (3.0%); and early increasing users (2.4%). Compared with non-users, fracture risk was not increased in either occasional users (aHR = 0.99, 95% confidence interval [CI] 0.99-1.00) or in decreasing users (aHR = 0.90, 95% CI 0.74-1.08). It was significantly higher in early increasing users (aHR = 1.86, 95% CI 1.62-2.14) and in late increasing users (aHR = 1.39, 95% CI 1.15-1.60). We observed similar trajectories and risk levels in the people older than 75 years.

CONCLUSION

Occasional BZD use, which is compatible with current recommendations, was not associated with an excess risk of the most frequent fall-related fractures in people older than 50 or 75 years.