Benzodiazepines (Benzos, BZDs)

A class or group of medications that calms the central nervous system (CNS).
Therefore, they are CNS depressants: anxiolytic and sedative-hypnotic medications.

Results in a calmer central nervous system and produces a sedative type or

tranquilizing effect on the body. There are different types of Benzos with various levels
of potency….some are very potent while others are mild, some act fast with a short
duration while others act slowly with a long duration.

How to recognize them? The middle of the generic drug name will have either “ze” or
“zo” and most end with “pam” or “lam” except, Clorazepate and Chlordiazepoxide.

Popular ones you may encounter in practice are: Alprazolam, Lorazepam,

Clonazepam, Temazepam, Diazepam, Midazolam

Used for?

Due to their ability to depress the central nervous system they can be used to treat a
variety of disorders where there is too much CNS stimulation occurring. Remember
various types of Benzos are available and some are better at treating certain conditions.

● Anxiety
● Alcohol withdrawal
● Seizures
● Insomnia
● Panic attacks
● Before a procedure with moderate sedation

Can be given various routes IV, PO, IM, rectally etc.

How do they work….mechanism of action?

Benzos amplify the effect of the neurotransmitter GABA (gamma-aminobutyric acid).

GABA is an inhibitory neurotransmitter.GABA is one of the main types of
neurotransmitters in the body that is an inhibitory neurotransmitter.

What’s the difference between excitatory and inhibitory neurotransmitters?

Excitatory: they excite and increase the potential of an action… like the neuron firing
and the message being carried out

● If we were treating anxiety or seizures, we wouldn’t want to excite the

neurons even more but calm them down.
Inhibitory: they impede and decrease the potential of an action by preventing an
action…hence stopping the message from being carried out….this helps create a CNS
depressant state or calming effect.

The neurotransmitter GABA binds to GABA receptors. Many GABA neurons are located
in the limbic system, which is the place in our brain that helps us process our emotions
and the way we behave. Now there are two types of GABA receptors: GABAA and
GABAB receptors

Benzos influence GABAA receptors.

GABAA receptors are ligand-gated or also called ionotropic receptors. These terms
describe how the receptor works to complete its job. When these GABA receptors are
influenced by BENZOS and binding occurs a channel opens to allow the movement of
ions, specifically chloride (CL-). This is going to majorly affect how the neuron fires
(hence it will inhibit action potential).

GABAA receptors have the following characteristics that allow them to work:

The receptor is designed with 5 sections. Notably called subunits:

● 2 alpha “α” subunits

● 2 beta “β” subunits
● 1 gamma “γ” subunit

In between these subunits, is a hole (pore). And when the channel opens due to
binding, it allows chloride to move through the channel into the cell. This causes
hyperpolarization and is responsible for inhibiting potential action…hence providing
calm, tranquilizing effects.

It has a total of three binding sites: Two sites for GABA (the neurotransmitter) and one
special site for Benzodiazepine (it has its own site). The two GABA binding sites are
found between each alpha and beta subunit, and the one Benzo site is found between
the alpha and gamma site.

So, what happens? Neurons release the neurotransmitter GABA. GABA rains down
onto GABA receptors and finds its binding site between the alpha and beta subunits.
Now if a BENZO has been administered, its chemical substance that is hanging out
finds its special binding site between the alpha and gamma subunit.

Then due to this binding the channel opens and through the pore of the receptor,
chloride flows down into the cell and hyperpolarizes it. This makes it negative and
decreases the firing potential, hence calm, tranquilizing effects. Therefore, it’s important
to note that the binding of benzos at its site, plus GABA binding at their own sites will
create this exaggerated effect of how GABA normally chills the body out….which results
in: decreased anxiety, stops seizures, helps a patient sleep, calms the withdrawal
effects of alcohol etc.

Now let’s talk about nursing responsibilities, side effects, and education pieces for the
patient.

BENZO

BEERS list: not appropriate for older adults (this is a list of medications created by the
American Geriatric Society that list medications that should not be prescribed for older
adults but avoided due to the older adults inability to handle the medication)

● Older adults are at risk for toxicity, dependence and abuse, increased risk
of falls and accidents, and altered mental status etc. If you would like to see
all the medications listed on this list by the American Geriatric Society you
can access it here: https://geriatrictoolkit.missouri.edu/drug/Beers-Criteria-
AGS-2019.pdf

ETOH, opioids, and other CNS depressants should be avoided while taking this
medication…EDUCATE this to the patient…increases risk for overdose and death (

Not recommended for long-term usage due to the high risk of dependence, withdrawal
symptoms, and abuse…best for short-term usage

● Can’t abruptly just stop the medication if taking over a period of time MUST
be tapered off
Zzzs (sleeping), hypnotic/sedative effect: educate about avoiding activities that require
focus and coordination

Overdose reversal with antidote: Flumazenil (use with caution…assess if benefits

greater than the risks)

● Be familiar with signs of toxicity…can happen due to inability to handle

the medication like older adults are more susceptible or when dependence
of the drug develops and abuse occurs (patient will need higher dosage to
keep getting the same effect) : “Abused”
● Altered mental status (very drowsy or coma, agitated,
confused)
● Bradycardia
● Unable to walk or coordinate movements (ataxia)
● Speech garbled or slurred
● Experience hallucinations and memory loss
● Decreased respirations