ISSN: 1230-2813
Advances in Psychiatry and Neurology/Postępy Psychiatrii i Neurologii
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SCImago Journal & Country Rank
4/2019
vol. 28
 
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abstract:
Case report

Steering the pharmacological treatment along different metabolic pathways in response to outlying complicated benzodiazepine withdrawal – a case study

Urszula Cieślak
,
Anna Basińska-Szafrańska

Adv Psychiatry Neurol 2019; 28 (4): 283-290
Online publish date: 2019/12/30
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Purpose
In benzodiazepine (BZD)-addicted patients, as in alcohol-dependent ones, the complicated withdrawal syndrome may be efficiently treated with accumulated long-acting benzodiazepine. The following work presents an alternative that can be used when the procedure fails.

Case description
A midazolam-dependent patient (1500 mg/d) was admitted to the hospital due to a withdrawal-induced status epilepticus. After treatment with barbiturates and megadoses of diazepam, the seizures subsided, but during the continuation of BZD (diazepam, clorazepate), consciousness disorders gradually developed culminating in a full loss of contact with the patient. The breakthrough occurred when lorazepam was used instead of previously administered substitute BZDs.

Comment
Extreme midazolam abuse (with a possible contribution of barbiturates at emergency admission) induced hydroxylating liver enzymes. This meant a rapid conversion of nominally long-acting substitutes, as those are similarly metabolized. This extremely facilitated elimination hindered their accumulation to the needed satiation level. Lorazepam, short-acting but bypassing the accelerated metabolic pathway, at sufficient doses provided the satiation necessary to stabilize the patient.

keywords:

metabolism, midazolam, benzodiazepine, withdrawal syndrome, lorazepam

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