Issues for surgery
For insomnia – exacerbation of symptoms if omitted.
Risk of withdrawal symptoms if omitted (see Further information).
Increased sedative effect and risk of cumulative central nervous system depression if continued.
Potential for post-operative delirium for elderly patients or those on long-term treatment, if continued (see Further information).
Advice in the perioperative period
Elective and emergency surgery
Continue.
Inform anaesthetist on day of admission of type and dose of benzodiazepine the patient usually takes so anaesthesia can be adjusted accordingly if necessary.
Post-operative advice
Restart post-operatively if appropriate.
Bear in mind the potential for post-operative confusion and delirium (POD), especially in those patients who are elderly and / or have been taking long-term temazepam (see Further information).
Patients who are discharged on the day of surgery after having received an anaesthetic and who usually take temazepam should be advised of the potential of enhanced drowsiness and psychomotor effects and counsel against undertaking skilled tasks (e.g. driving).
Interactions with common anaesthetic agents
Central Nervous System (CNS) depression
Also see Interactions with other common medicines used in the perioperative period.
Temazepam has CNS depressant effects which may be additive with other medicines that also have CNS depressant effects such as:
- inhalational and intravenous anaesthetics
- local anaesthetics
- opioids
- other benzodiazepines
Opioids
Giving benzodiazepines with opioids during anaesthesia may reduce the dose required of both drugs. The patient should be monitored and adjustments made according to the effect.
Temazepam is used concomitantly with opioids, possible euphoria may be enhanced; this may lead to increased psychological dependence.
The current recommendation from manufacturers for the prescribing of temazepam with opioids is that concurrent use should be reserved for patients in whom alternative treatment options are not possible or are inadequate. If the decision is made to prescribe temazepam with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible.
Interactions with other common medicines used in the perioperative period
CNS depression
Also see Interactions with common anaesthetic agents for information on opioids.
Temazepam has CNS depressant effects which may be additive with antiemetics that also have CNS depressant effects such as cyclizine, droperidol and prochlorperazine.
Further information
Withdrawal
Sudden discontinuation of temazepam is associated with withdrawal symptoms including confusion, toxic psychosis, convulsions, delirium and rebound effects. Doses should be reduced gradually.
Withdrawal symptoms can occur within a day after stopping temazepam.
Post-operative delirium (POD)
POD has been shown to be a predictor of death, increased mortality, and longer duration of stay especially in ventilated patients. Benzodiazepines have been found to increase the frequency of POD. The frequency may be higher in elderly patients and those on long-term benzodiazepines. In addition, if a patient develops POD, consideration should be given to not using benzodiazepines as the first-line agents for treatment.
References
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 10th July 2019]
Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. BJA: British Journal of Anaesthesia. 2012; 108(4):562-571
Carter EL, Adapa RM. Adult epilepsy and anaesthesia. BJA Education. 2015; 15(3):111-117
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 29th August 2019
Diazepam. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 29th August 2019]
Summary of Product Characteristics – Xanax® (alprazolam) 500 micrograms. Pfizer Limited. Accessed via www.medicines.org.uk 07/09/2019 [date of revision of the text January 2019]
Summary of Product Characteristics – Frisium® (clobazam) 10mg Tablets. SANOFI. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text July 2018]
Summary of Product Characteristics – Diazemuls Emulsion® (diazepam). Accord-UK Ltd. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text August 2019]
Summary of Product Characteristics – Clonazepam Auden 2mg Tablets. TEVA UK Limited. Accessed via www.mhra.gov.uk 11/09/2019 [date of revision of the text September 2018]
Summary of Product Characteristics – Diazepam Tablets BP 10mg. Accord-UK Ltd. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text December 2018]
Summary of Product Characteristics – Dalmane® (flurazepam) 15mg Capsules. Mylan. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text July 2018]
Summary of Product Characteristics – Loprazolam 1mg Tablets. Zentiva. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text August 2018]
Hase I, Oda Y, Tanaka K. I.v. fentanyl decreases the clearance of midazolam. British Journal of Anaesthesia. 1997; 79:740-743
Summary of Product Characteristics – Lorazepam 2.5mg Tablets. Genus Pharmaceuticals. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text October 2018]
Summary of Product Characteristics – Nitrazepam Tablets 5mg. Accord-UK Ltd. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text December 2018]
Summary of Product Characteristics – Oxazepam Tablets 10mg Tablets. Genus Pharmaceuticals. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text October 2018]
Summary of Product Characteristics – Temazepam 20mg Tablets. Mylan. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text December 2017]
Summary of Product Characteristics – Zolpidem Tartrate 10mg Tablets. Zentiva. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text January 2019]
Summary of Product Characteristics – Zopiclone 7.5mg Tablets. Accord-UK Ltd. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text June 2019]
Summary of Product Characteristics – Dormagen® (lormetazepam) 1mg Tablets. Genus Pharmaceuticals. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text October 2018]
Summary of Product Characteristics – Chlordiazepoxide 10mg Capsules. Kent Pharmaceuticals Ltd. Accessed via www.medicines.org.uk 11/09/2019 [date of revision of the text August 2018]
Atracurium Besilate. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 29th August 2019]
Zhang Y, Tany Y, Yang J et al. Perioperative Use of Benzodiazepines: A Reconsideration of Risks and Benefits. J Anaesth Perioper Med. 2018; 5(1):34-40
Kudoh A, Takase H, Takahira Y. Postoperative confusion increases in elderly long-term benzodiazepine users. Anesthesia & Analgesia. 2004; 99(6):1674
Lepouse C, Lautner CA, Liu A et al. Emergence delirium in adults on the post-anaesthesia care unit. British Journal of Anaesthesia. 2006; 96(6):747-753