Midazolam belongs to a group of drugs that act on the central nervous system: benzodiazepines. It is a drug that has a hypnotic, sedative, anticonvulsant and anxiolytic effect. Midazolam is mainly used in inpatient treatment by anesthetists or as tablets to treat severe insomnia.

Action of midazolam

Benzodiazepines are a group of substances that intensify the effects of a naturally occurring neurotransmitter, i.e. gamma-aminobutyric acid. This acid (GABA for short) is the main inhibitory neurotransmitter. By increasing its transmission, the effect of sedation, calming myorelaxation and increasing the seizure threshold is obtained.

After administering the drug, the patient quickly falls asleep, the duration of which should be continuous for 7 to 8 hours. Midazolam is a potent benzodiazepine, the effect of which can be seen just minutes after administration. It also has an anticonvulsant effect, therefore it is used during episodes of epilepsy.

Midazolam in tablet form is mainly used to treat severe insomnia. Because it is in the group of strong, fast-acting benzodiazepines, specialists use it only in a difficult situation, when the patient cannot function normally.

Doctors say that it is best to administer BDZ to people who experience severe stress and anxiety simultaneously with insomnia. Benzodiazepines are drugs that further calm the patient and allow him to fall asleep.

In inpatient treatment, midazolam is used to sedate the patient, in premedication before anesthesia. In the mentioned cases, its amnestic effect is also beneficial.

This means that after administration of midazolam, after it reaches its maximum concentration in the blood, the patient may not remember the events from that moment. This is beneficial because some patients feel anxious about the procedure or surgery, so making them unconscious prevents them from developing a trauma or panic attack.

Indications for the use of midazolam

Midazolam is used in situations such as:

  • treatment of insomnia,
  • premedication before surgery,
  • preoperative anxiety,
  • periodperioperative,
  • status epilepticus,
  • acute movement disorders.

Midazolam can be used in the epileptic state with great efficiency. It can be administered intramuscularly, which is a great help for the first aid provider and shortens the time of medical intervention.

There are reports of the efficacy of intranasal or buccal administration of midazolam in the setting of epilepsy. However, at the moment these forms are not available in Poland.

It should be remembered that the decision to give midazolam to a person with epilepsy during an attack can be made by any attending physician or paramedic.

Midazolam is also used in acute movement disorders and acute agitation, which results from:

  • from a general medical condition,
  • intoxication with psychoactive substances,
  • in withdrawal syndrome and mental illness.

Typically, if the cause of motor agitation is unknown, a physician will order a toxicology test to determine the correct target treatment. The administration of benzodiazepines in such states is only a supportive measure, thanks to which the patient regains peace.

Dosage of midazolam

The golden rule of treatment with benzodiazepines is to administer them in the lowest effective dose for the shortest possible period of time. So, the use of tablets for the treatment of insomnia should be no more than 2 weeks. It is necessary to adjust the dose to the patient by a specialist doctor.

There are no hard and fast rules regarding the dosage of midazolam. The doctor takes into account the patient's condition, severity of symptoms, age, and comorbidities. The doctor's approach to stopping the drug is the same.

Do not stop taking your medication suddenly. This decision must be made by the attending physician. There are patterns of drug withdrawal, but it is a tedious and often ineffective process.

According to statistics, about 40 percent of patients are unable to stop taking BDZ the first time. Long-term use of drugs from this group, especially those with such strength as midazolam, causes the patient's physical and mental dependence.

At the same time, it begins to develop tolerance to the drug, so the patient feels the need to increase the dose to obtain the same effect as at the beginning of the therapy. The doctor should check the patient's condition several times a week when stopping this medication, and take into account the need to modify the dose or to extend the time of discontinuation of the drug.

Psychotherapy is used in most patients concurrently with pharmacological treatment. which is designed to help the patient in the fight againstinsomnia. There are cases where the patient's condition is so severe that complete drug discontinuation is impossible. In such a situation, the doctor may advise the patient to take the drug two or three times a week.

The drug should be taken before bedtime because midazolam works quickly and the patient may feel very tired within a short time. The tablet should be washed down with water.

The patient should always follow the doctor's instructions. The dose may need to be reduced in the elderly and in those with kidney or liver problems. These people may be exposed to an increased effect of the drug and its accumulation in the body.

In the case of an injectable solution, the question of dosage is always decided by the specialist anesthetist or other physician responsible for the patient. It is very important that the patient is not infused too quickly or overdosed as this may lead to respiratory depression in the patient.

It is possible to administer the solution rectally to the patient. This solution is usually appropriate in children, when the doctor wants to avoid administering the drug intramuscularly because it is a painful injection.

Contraindications to the use of midazolam

You should not take the drug if:

  • the patient is hypersensitive to midazolam, other benzodiazepines or any of the excipients,
  • the patient suffers from severe respiratory failure,
  • the patient suffers from severe liver failure,
  • the patient has night apnea,
  • the patient is a child,
  • the patient suffers from muscle fatigue,
  • the patient is simultaneously taking ketoconazole, itraconazole, voriconazole, HIV protease inhibitors.

Precautions and interactions

Midazolam should be administered with particular caution to patients at risk, i.e .:

  • adults over 60 years of age,
  • chronically ill and debilitated patients,
  • patients with respiratory diseases, especially respiratory failure,
  • patients with renal or hepatic insufficiency,
  • for patients with circulatory instability
  • and children.

These patients require dose reduction and continuous monitoring of vital signs after drug administration.

The physician should make the patient aware of the risk of developing tolerance to midazolam, especially if the patient is taking the drug for an extended period.

After treatment is discontinued, so-called rebound insomnia. This is not something the patient should consider to confirm that they need to take the medicine again. This is a typical symptom that will be transientresults from the body's habituation to taking this substance.

This symptom should disappear after a week. Unfortunately, unaware patients often take the drug again, thinking that without it they will not be able to sleep.

The effect of oblivion is completely natural and it does not mean that the patient should underestimate it. Amnesia usually occurs within hours of taking the medicine. A patient who has taken the drug to fall asleep has nothing to fear.

However, if the drug has been administered to prepare for surgery, or to sedate the patient prior to surgery, the patient should not be released from hospital immediately following the medical procedure.

If the doctor decides to release the patient home, he or she should be with a relative who will help him get home safely.

In elderly patients and in children, the so-called paradoxical reactions after drug administration. They consist in the development of aggressive behavior, state of agitation and restlessness in the patient.

The use of strong benzodiazepines in the elderly is also not recommended due to the risk of cognitive impairment, which may persist even after discontinuation of the drug. Elderly people also have an increased risk of falling during therapy, which is related to reduced motor coordination.

You should not take drugs that depress the nervous system together with midazolam. These drugs increase its side effects and increase the risk of respiratory depression and cardiac arrest. Likewise, you shouldn't drink alcohol during therapy.

Drugs that deepen the sedative effect of midazolam and increase the risk of side effects include:

  • opioid painkillers or cough suppressants
  • antihistamines,
  • sedative antidepressants,
  • antipsychotics,
  • barbiturates,
  • propofol,
  • ketamine,
  • etomidat,
  • centrally acting antihypertensive drugs.

The drug should not be used in patients who abuse alcohol or are addicted to other substances. These patients are more likely to become addicted to midazolam.

There is a risk of withdrawal syndrome after drug withdrawal.

Symptoms are:

  • headaches,
  • muscle aches,
  • increased anxiety,
  • feeling tense,
  • restlessness,
  • irritability.

The risk of these symptoms increases if the drug is suddenly discontinued, so gradual treatment is recommendedputting down.

Drugs that increase the effect of midazolam while extending its duration of action and increasing the risk of side effects are:

  • ketoconazole,
  • itraconazole,
  • voriconazole,
  • HIV protease inhibitors,
  • verapamil,
  • diltiazem,
  • fluconazole,
  • clarithromycin,
  • telithromycin,
  • erythromycin,
  • nefazodone,
  • aprepitat,
  • tebimorelin.

Concomitant use of these drugs and midazolam is not recommended and should only be taken at the doctor's decision. At the same time, the patient should inform the doctor about all medications he is taking at a given time and about the treated diseases, so that the doctor can make a responsible decision about benzodiazepine treatment.

Substances that weaken the effect of midazolam are:

  • rifampicillin,
  • phenytoin,
  • carbamazepine,
  • efawirenz
  • and St. John's wort.

If you are taking any of the above medications and midazolam at the same time, please inform your doctor as it may be necessary to increase the dose.

Drugs that stimulate the central nervous system, such as physostigmine, reverse the hypnotic effects of midazolam.

Midazolam and pregnancy

It is not recommended to use midazolam during pregnancy. There are insufficient studies to confirm the safety of this drug in the first and second trimesters of pregnancy. Some infants born to women who received high doses of midazolam during the third trimester or during labor have had arrhythmias, hypotonia, impaired suckling reflex, hypothermia, and moderate respiratory depression.

Breastfeeding women should wean their babies from the breast during treatment with midazolam as this drug passes into breast milk. In such situations, children may develop respiratory depression or sedation.

Midazolam and driving

After taking midazolam, driving may be difficult. This is mainly due to the side effects caused by the drug, such as drowsiness, prolonged reflex time, and ataxia. According to research, the risk of a collision while taking benzodiazepines is similar to the risk of driving a car after drinking alcohol.

Side effects of midazolam

The most common side effects reported by patients are:

  • confusion, emotional disturbances, which may appear especially at the beginning of treatment, but are transient as the therapy progresses,
  • if patientbefore treatment, he had depression, it may reveal itself after adding midazolam to the therapy,
  • paradoxical reactions concerning especially the elderly, including restlessness, agitation, irritability, aggression
  • rebound syndrome after abrupt drug withdrawal or withdrawal syndrome,
  • mental and / or physical addiction,
  • sleepiness,
  • pain and dizziness,
  • ataxia,
  • retrograde amnesia,
  • double vision,
  • muscle weakness,
  • weariness,
  • In rare cases, respiratory depression, which is at increased risk in people who suffer from respiratory disease or are taking drugs that act similar to benzodiazepines.

Benzodiazepines are considered safe drugs if they are taken as intended and prescribed by a doctor. The patient should be under the care of a specialist during midazolam therapy. Overdosing is not usually life-threatening. After taking too much of the drug, the patient may feel:

  • increased sleepiness,
  • ataxia,
  • dysarthria
  • and nystagmus.

In severe cases, the patient may fall into a coma.

Category:

He alth