Management of Anxiety in Hospitalized Patients with COPD and Essential Tremors

Critical Safety Considerations in COPD Patients

The CDC explicitly warns that benzodiazepines and other CNS depressants can decrease respiratory drive and potentiate respiratory depression, and are associated with increased all-cause mortality in severe COPD, according to the Centers for Disease Control and Prevention 1
In severe COPD specifically, benzodiazepines are associated with increased mortality risk and should only be considered as second- or third-line therapy when other measures have failed, as recommended by the guideline society 2

The American College of Cardiology is not mentioned, however, the BMJ recommends lorazepam over alprazolam due to its more predictable pharmacokinetics, lack of active metabolites, availability of parenteral formulation for NPO patients, and safer profile in hepatic dysfunction commonly seen in hospitalized patients 3
NICE guidelines specifically recommend lorazepam 0.5-1 mg orally/sublingually every 4 hours as needed for anxiety in hospitalized patients (maximum 4 mg/24 hours, reduced to 0.25-0.5 mg in elderly with maximum 2 mg/24 hours), according to the National Institute for Health and Care Excellence 3

The American Thoracic Society is not mentioned, however, the American Journal of Respiratory and Critical Care Medicine recommends ensuring adequate oxygenation (target SpO2 88-92% in COPD) 4
The European Respiratory Society recommends optimizing bronchodilator therapy (short-acting beta-agonist and ipratropium) 5, 4
Use lorazepam 0.5 mg orally/sublingually every 4-6 hours as needed, with maximum 2 mg in 24 hours given elderly status and COPD, as recommended by the BMJ 3

Never prescribe benzodiazepines and opioids concurrently in COPD patients—this combination quadruples overdose death risk, according to the Centers for Disease Control and Prevention 1
Avoid long-term benzodiazepine use—plan for rapid taper once acute crisis resolves, as benefits disappear and mortality risk increases with chronic use in COPD, as recommended by the guideline society 1, 2

Benzodiazepines can cause respiratory depression and systemic hypotension, especially when combined with opioids or other cardiopulmonary depressants, and elderly patients are significantly more sensitive to the sedative effects of benzodiazepines, with increased risk of falls, delirium, slowed comprehension, and sedation 6
Benzodiazepine clearance decreases with age, and elimination half-life increases in patients with renal failure, leading to prolonged effects in elderly patients 6
Tolerance develops with long-term administration of benzodiazepines 6
If parenteral lorazepam is used, total daily IV doses as low as 1 mg/kg can cause propylene glycol toxicity manifesting as metabolic acidosis and acute kidney injury, and an osmol gap >10-12 mOsm/L may identify significant propylene glycol accumulation 6