Chlordiazepoxide

Benzodiazepines have been associated with anterograde amnesia (Nelson 1999).

May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).

Paradoxical reactions, including hyperactive or aggressive behavior, have been reported with benzodiazepines, particularly in adolescent/pediatric or psychiatric patients. Disease-related concerns:

Use caution in patients with depression, particularly if suicidal risk may be present.

Use with caution in patients with a history of drug abuse or acute alcoholism; potential for drug dependency exists. Psychological and physical dependence, as well as tolerance to sedative and anticonvulsive effects, may occur with prolonged use (Vinkers 2012).

Use with caution in patients with hepatic impairment.

Use with caution in patients with porphyria.

Use with caution in patients with renal impairment.

Use with caution in patients with respiratory disease (Smoller 1996). Concurrent drug therapy issues:

The concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions for more detailed information. Special populations:

Use with caution in debilitated patients; active metabolites with extended half-lives may lead to delayed accumulation and adverse effects, including ataxia and over-sedation.

Avoid use; if used, use with caution in the elderly; active metabolites with extended half-lives may lead to delayed accumulation and adverse effects, including ataxia and over-sedation.

Use with extreme caution in patients who are at risk of falls; benzodiazepines have been associated with falls and traumatic injury (Nelson 1999).

Use with caution in children; active metabolites with extended half-lives may lead to delayed accumulation and adverse effects, including ataxia and over-sedation. Other warnings/precautions:

Chlordiazepoxide is a long half-life benzodiazepine. Duration of action after a single dose is determined by redistribution rather than metabolism. Tolerance does not develop to the anxiolytic effects (Vinkers, 2012). Chronic use of this agent may increase the perioperative benzodiazepine dose needed to achieve desired sedative effect.

Rebound or withdrawal symptoms may occur following abrupt discontinuation or large decreases in dose. Use caution when reducing dose or withdrawing therapy; decrease slowly and monitor for withdrawal symptoms. Flumazenil may cause withdrawal in patients receiving long-term benzodiazepine therapy.