Benzodiazepines for emergency management of anxiety associated with severe acute breathlessness in palliative care

There is insufficient evidence to support the use of benzodiazepine monotherapy for breathlessnessHenson, 2020Hui, 2021Simon, 2016Zemel, 2021. However, for the emergency management of anxiety associated with severe acute breathlessness, benzodiazepine therapy can be effective as an adjunct to opioids and general measures (see Principles of emergency management of severe acute breathlessness in palliative care).

For patients with palliative care needs who have severe anxiety or distress associated with severe acute breathlessness, and who have not responded to nonpharmacological management and opioid therapy, consider adding a benzodiazepineHui, 2021Simon, 2016Zemel, 2021.

For patients being treated in a monitored acute care setting (eg emergency department, intensive care unit), use:

1midazolam 1 to 2 mg intravenously, repeated at 5- to 10-minute intervals as required; seek specialist advice if 3 doses do not improve anxiety midazolam

OR

1midazolam 2.5 to 5 mg subcutaneously, repeated at 15-minute intervals as required; seek specialist advice if 3 doses do not improve anxiety midazolam

OR

2clonazepam 0.2 to 0.5 mg subcutaneously, repeated at 30-minute intervals as required; seek specialist advice if 3 doses do not improve anxiety1 clonazepam

OR

2clonazepam 0.2 to 0.5 mg sublingually, repeated at 30-minute intervals as required2; seek specialist advice if 3 doses do not improve anxiety1. clonazepam

For patients not being treated in a monitored acute care setting (eg patient is being treated in an inpatient ward or residential aged-care facility), the interval between benzodiazepine doses is increased to reduce the risk of toxicity. Use:

1midazolam 2.5 to 5 mg subcutaneously, repeated 1-hourly as required; seek specialist advice if 3 doses do not improve anxiety midazolam

OR

2clonazepam 0.2 to 0.5 mg subcutaneously, repeated 2-hourly as required; seek specialist advice if 3 doses do not improve anxiety1 clonazepam

OR

2clonazepam 0.2 to 0.5 mg sublingually, repeated 2-hourly as required2; seek specialist advice if 3 doses do not improve anxiety1 clonazepam

OR

2lorazepam 0.5 to 1 mg orally, repeated 1-hourly as required3; seek specialist advice if 3 doses do not improve anxiety. lorazepam

For management of breathlessness in the last days of life, see Breathlessness causing distress in the last days of life.

If death appears imminent, and the patient is distressed by their breathlessness, see Catastrophic terminal events in palliative care for management.

1 Clonazepam has a long half-life (30 to 40 hours) and ongoing use of frequent doses can result in accumulation and excessive sedation. Once symptoms have improved, reduce the frequency of as-required doses. Alternatively, midazolam has a shorter half-life and can be used for as-required doses.Return
2 Two to five drops of clonazepam 2.5 mg/mL oral liquid is equivalent to clonazepam 0.2 to 0.5 mg. Do not count drops directly into the mouth; count drops into a spoon first.Return
3 Lorazepam tablets can be administered sublingually but are less bioavailable than when administered orally.Return