Concomitant use of alcohol/CNS depressantsThe concomitant use of Valium with alcohol and/or CNS depressants should be avoided. Such concomitant use has the potential to increase the clinical effects of Valium possibly including severe sedation, clinically relevant respiratory and/or cardio-vascular depression (see section 4.5).
Medical history of alcohol or drug abuseValium should be used with extreme caution in patients with a history of alcohol or drug abuse.Valium should be avoided in patients with dependence on CNS depressants including alcohol.An exception to the latter is the management of acute withdrawal reactions.
ToleranceSome loss of efficacy to the hypnotic effects of benzodiazepines may develop after repeated use for a few weeks.
DependenceUse of benzodiazepines may lead to the development of physical and psychological dependence upon these products. The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a history of alcohol or drug abuse or in patients with marked personality disorders. Regular monitoring in such patients is essential, routine repeat prescriptions should be avoided and treatment should be withdrawn gradually.
WithdrawalOnce physical dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms. These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability. In severe cases the following symptoms may occur: derealisation, depersonalisation, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations or epileptic seizures.
Rebound insomnia and anxietyA transient syndrome whereby the symptoms that led to treatment with a benzodiazepine recur in an enhanced form, may occur on withdrawal of treatment. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances and restlessness. Since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually.
Duration of treatmentThe duration of treatment should be as short as possible (see section 4.2) depending on the indication, but should not exceed 4 weeks for insomnia and eight to twelve weeks in cases of anxiety, including a tapering off process. Extension beyond these periods should not take place without re-evaluation of the situation.It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased. Moreover it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.There are indications, that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. When benzodiazepines with a long duration of action are being used it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.
AmnesiaIt should be borne in mind that benzodiazepines may induce anterograde amnesia. Anterograde amnesia may occur using therapeutic dosages, the risk increasing at higher dosages. Amnestic effects may be associated with inappropriate behaviour. The condition occurs most often several hours after ingesting the product and therefore to reduce the risk patients should ensure that they will be able to have an uninterrupted sleep of 7 8 hours (see section 4.8).
Psychiatric and 'paradoxical' reactionsReactions like restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepines. Should this occur, use of the drug should be discontinued. They are more likely to occur in children and older people.
Specific patient groupsBenzodiazepines should not be given to children without careful assessment of the need to do so; the duration of treatment must be kept to a minimum. Since the safety and effectiveness in paediatric patients below the age of 6 months have not been established, Valium should be used in this age group with extreme caution and only when other therapeutic alternatives are not available.Older and debilitated patients should be given a reduced dose (see section 4.2). Due to the myorelaxant effect there is a risk of falls and consequently hip fractures in older people. A lower dose is also recommended for patients with chronic respiratory insufficiency due to the risk of respiratory depression. Benzodiazepines are not indicated to treat patients with severe hepatic insufficiency as they may precipitate encephalopathy. In patients with chronic hepatic disease, dosage may need to be reduced.The usual precautions in treating patients with impaired renal function should be observed. In renal failure the half-life of diazepam is unchanged, therefore no dosage adjustments are required in such patients.Benzodiazepines are not recommended for the primary treatment of psychotic illness.Benzodiazepines should not be used alone to treat depression or anxiety associated with depression (suicide may be precipitated in such patients).In cases of loss or bereavement, psychological adjustment may be inhibited by benzodiazepines.Patients with rare hereditary problems of galactose intolerance, (the Lapp lactase deficiency or glucose-galactose malabsorption) should not take this medicine.