Talk:Benzodiazepine/GA2

GA Review

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1. Does not yet fullfil WP:LEAD --Doc James (talk · contribs · email) 20:58, 5 April 2009 (UTC)

I read WP:LEAD and made changes according to it Doc. I have fixed the lead according to recommendations of WP:LEAD. I summarised important sections of the article which was absent from the lead. I also removed non notable content which was not discussed in the main article. I think that I have resolved this?--Literaturegeek | T@1k? 21:57, 5 April 2009 (UTC)

I have now expanded further on the lead to to include all important aspects of the drug class benzodiazepine and have seperated the lead into 3 paragraphs.--Literaturegeek | T@1k? 00:33, 6 April 2009 (UTC)

I believe that I have removed all the glaring problems with the article now. The majority of the references are to good quality secondary sources, mostly reviews and meta analysis papers. All that is needed now is a critical review to see what else I am missing. No rush.--Literaturegeek | T@1k? 06:01, 6 April 2009 (UTC)

Hi - not sure where this is up to but will have a lookover to see what needs doing. Casliber (talk · contribs) 10:58, 18 April 2009 (UTC)

• Side-effects section would be better in prose format - some of these effects are common and some very rare - the layout is misleading as this is not differentiated. - Done

• Not really worthwhile mentioning cimetidine as no-one prescribes it anymore as it has been well and truly superseded. - removed - Done

• Article needs to mention that short-acting benzos are worse for causing physical dependence and withdrawal. - Done

• The first sentence - The benzodiazepines (pronounced /ˌbɛnzoʊdaɪˈæzɨpiːn/, often abbreviated to "benzos") first introduced to the market in 1960 are a commonly prescribed class of psychoactive drugs with varying sedative, hypnotic, anxiolytic (antianxiety), anticonvulsant, muscle relaxant and amnesic properties. is unwieldy. remove bolded bit and place that in a sentence after and also mention chlordiazepoxide in lede - Done

• The Acute mania is misleading. benzos are used for sedation in any agitated state in psychiatry, often in acute psychoses such as schizophrenia and mania. This is a nonspecific effect. clonazepam is rarely prescribed for mania as a sole agent. - Done

• ref 61 [1] is not a review article - funnily enough there is a link to [2], te title of which looks like it might disagree with the first ref (and the article). I am not sure I can get access to Pain but will have a look. I had not heard of chronic pain as such being a contraindication, nor chronic psychosis (a term I have not heard of as such, this would be schizophrenia). The general long term nature of the problem is the issue, but the text makes it look like it might be something specific. Anyway, finding a review article would be prudent. - removed - Done

• To qualify for comprehensiveness - article needs to place their commercial use in context - eg replaced barbiturates and are now starting to be replaced themselves by Z drugs (though very early days yet). This should be discussed in some detail, and also mentioned in lead - Done, but may need some further expanding, eg regarding overdose etc?

• Subcats of short, medium and long-acting need to be in lead. - Done

• diazepam needs to be mentioned in lead. - Done

• need to avoid weasel words - I will try and correct some to illustrate. Done

• there is redundancy and repetitiveness in the prose in places. - I will trim some and show. - Not sure if I have resolved this? I rearranged the lead. Does it need more work?

Thank you for your suggestions Casliber which I have tried to implement in the article. I have edited in bold and italics my words beside your words above. In the UK most sources, either say contraindicated or "not recommended" or else no evidence of effectiveness etc. Why some medical sources in the UK say contraindicated in the UK is probably because of the Committee on Safety of Medicines review of benzos in 1980 and 1988 when a senior psychiatrist in the UK called professor Rawlins was on the board. I recently read a quote by him where he said long term use of benzodiazepines is associated with increased risk of hallucinations. It was quote from a drug dependence conference or meeting in one of their annual reports. Whether he got his views from personal experience as a psychiatrist or whether it is based on the peer reviewed literature or not I don't know but I am guessing that his views as well as others on the CSM panel reviewing benzodiazepines influenced policy on use of benzodiazepines in "chronic psychosis" in the UK. Perhaps, it is because cognitive impairment is a risk factor for worse schizophrenia outcomes and that is why they are contraindicated in chronic psychotic states? Again I am speculating. It is referred to in the British National Formulary as chronic psychosis. Perhaps they are trying to incorporate basically every form of chronic psychosis? Korsacoffs, brain damage related, schizophrenia etc etc and that is why they chose the term chronic psychosis? I dunno I am only guessing.--Literaturegeek | T@1k? 00:07, 19 April 2009 (UTC)

Any further suggestions are welcome.--Literaturegeek | T@1k? 00:08, 19 April 2009 (UTC)

• A set of pages I have found extremely useful are these - User:Tony1/How_to_satisfy_Criterion_1a for further improving writing style. I will keep looking. Casliber (talk · contribs) 02:28, 19 April 2009 (UTC)

• Need a timeframe for The benzodiazepines largely replaced the barbiturates as commonly prescribed sedative hypnotics. - Done

I shall work on the writing style over the next few days or week. Thanks for the link. It looks like a great help.--Literaturegeek | T@1k? 22:18, 19 April 2009 (UTC)

The lead looks good the article looks comprehensive. Only other comment I have is maybe a bit of discussion is needed on the rates of side effects. ie which are most common etc. Falls in the elderly is a major one for example as it can lead to head injuries and hip fracture. Also it is commonly used in dementia off label for behavioral control. They of course are not effective but I still think this should be discussed.

From uptodate "Benzodiazepines — Benzodiazepines have limited value in patients with AD. They are not recommended for the management of neuropsychiatric symptoms of dementia. One randomized controlled trial of a benzodiazepine for neuropsychiatric symptoms of dementia found benefit for both intramuscular lorazepam and intramuscular olanzapine compared with placebo at two hours after treatment; the benefit of lorazepam was not sustained at 24 hours on one outcome scale [65].Benzodiazepine side effects include worsening gait, potential paradoxical agitation, and possible physical dependence. Benzodiazepine use should be limited to brief stressful episodes, such as a change in residence or an anxiety-provoking medical event [66]."

Lexidrugs breaks up side effects into percentages for lorazepam for example they are "ADVERSE REACTIONS SIGNIFICANT >10%:Central nervous system: Sedation Respiratory: Respiratory depression 1% to 10%: Cardiovascular: Hypotension Central nervous system: Confusion, dizziness, akathisia, ataxia, headache, depression, disorientation, amnesia etc"

Do not know if this would be possible for the group as a whole.--Doc James (talk · contribs · email) 05:21, 22 April 2009 (UTC) Found the section that discusses it. --Doc James (talk · contribs · email) 05:23, 22 April 2009 (UTC)

I will expand the information on use of benzos in dementia. The literature for the most part talks negatively of using benzos in the elderly even short term and in dementia it is even more negative on their use. The side effect profile differs little from one benzo to the other, apart from half life related side effects eg withdrawal severity, accumulation which is discussed in article. In the British National Formulary it says "see under diazepam" for the various benzos or in the case of hypnotics "see under nitrazepam". It doesn't list any additional side effects for the individual benzos so side effects are very much a class effect. I cannot find a source which gives percentages. Do you have a link?--Literaturegeek | T@1k? 16:54, 22 April 2009 (UTC)

Ok, I have tidied up the article some more, removed more redundancy and done more tweaks. I also expanded the history section. The article still has quite a way to go to reach featured article standard but has it reached a good article status yet or is more work still needed?--Literaturegeek | T@1k? 00:06, 26 April 2009 (UTC)

Links and References Benzodiazepine ambiguous links:

• Agitation (emotion) [redirects to Agitation]
• Benzodiazepines is a self-redirect.
• Beta
• Oral contraceptives [redirects to Oral contraceptive]
• Restlessness [redirects to Agitation]
• Z drugs [redirects to Z-drug]

The three links to : http://www.bnf.org/bnf British National formulary are dead and have to be replaced. --Stone (talk) 07:38, 2 May 2009 (UTC)

Thank you very much Stone for finding these problems. I have now corrected them. I couldn't find however, in the article where benzodiazepines was wiki linked.--Literaturegeek | T@1k? 06:28, 3 May 2009 (UTC)

Few more comments

The section Benzodiazepines and their therapeutic has a number of heading some which are listed by action and the other by condition treated. Might be better to stick with one an alphabetize.--Doc James (talk · contribs · email) 02:50, 16 May 2009 (UTC)

Ok thank you for the suggestion. I have made this change and alphabeticalised the list.--Literaturegeek | T@1k? 11:22, 16 May 2009 (UTC)

Sorry all, I was the one who attached my name to this GAN as a reviewer. I have just asked around quickly to see if anyone else has some ideas, but will give it a least read-over later today before (hopefully) passing. I thought it was worth striking while the iron was hot and propel it as far forward along the road to FAC. Is an important article to do a good job on and kudos LG for taking it on :) Casliber (talk · contribs) 01:00, 18 May 2009 (UTC)

Final couple of things

• Some anticonvulsants are gaining attention for their anxiolytic properties and thus are a potential rival to the benzodiazepines in the treatment of anxiety. - I worry about the wording of this. Yes, there are review articles reporting on research into these drugs, but they are not at all used for this practice in any setting I have seen. I think the term 'research' needs to be included to show this is restricted to research only. Casliber (talk · contribs) 13:21, 19 May 2009 (UTC) - Done

• however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks -whoa, I have never seen that I must admit. Not sure what to do about this one. Would have to be pretty rare.

Comment, I don't mind deleting this but I got the information from the British National Formulary. They actually use the term "very occasionally" so will for now change the article to say "very occasional" rather than "occasionally". Examples where this could be given may include in an emergency room setting where they quickly need to settle the patient so they can deal with other emergency cases or where the panic attack is extremely severe and rapid relief is required. Another example may include where it is complicated by an acute drug induced psychosis such as someone who is in extreme panic from a "bad trip" on LSD or mushrooms but is not in control of judgement enough to swallow a tablet or where the panic is very severe the person is acutely and perhaps dangerously agitated?--Literaturegeek | T@1k? 15:22, 19 May 2009 (UTC)

• Alternatively nitrous oxide can be administered in dental phobia due to its sedative and dissociative effects, its fast onset of action and its extremely short duration of action. - off-topic? Do we really need it here? Mainly asking as the article is pretty long as is. - Agreed. Those wanting more info on the subject can click on the dental phobia link.

• Benzodiazepines once bound to the benzodiazepine receptor, the benzodiazepine ligand locks the benzodiazepine receptor into a conformation in which it has a much higher affinity for the GABA neurotransmitter. - has the punctuation gone awry in this sentence? - Yes. There should not be a comma before the word "the". Correct?

• In the Drug misuse section, after the intial use of "misuse", I'd use "use" for "misuse" elsewhere in a more specific settling. We don't say "guns are misused for killing people", or "boltcutters are misused to break open padlocks to breat and enter property". Looks funny. Casliber (talk · contribs) 13:44, 19 May 2009 (UTC) - Agreed. I replaced misuse with use but for a couple of instances I left misuse where I thought removal would make the article worse but if disputed feel free to edit those away. Don't want it to get in way of good article pass.

Fix (or convince me otherwise) these and we're done. For bonus points to FAC, the prose is a bit repetitive in places and can be trimmed and reworked, especially in the history section, and I strill think we'd be better with a common/rare listing within side effects. Otherwise, just about over the line here. Casliber (talk · contribs) 13:47, 19 May 2009 (UTC)

I have added a bold word seperated from your comments with a dash for my comments inserted after your comments. I will work on the prose history section later on this evening. I believe that I can get the common rare listing. Suggestion, maybe you should pass the article as a Good Article. Then over the next 24 - 48 hours I make the changes suggested and then I could submit it to featured article review? Would you be interested in reviewing it for featured article?--Literaturegeek | T@1k? 15:22, 19 May 2009 (UTC)

Thank you for thanking me on my work to the benzo article. It has been a gradual process over the past couple of years. Like you say it is an important article--Literaturegeek | T@1k? 15:22, 19 May 2009 (UTC)

As far as frequency of side effects, I can get stats on individual benzodiazepines which give a percentage eg less than 1%, less than 10% etc but can't find stats for benzodiazepines as a class. There doesn't seem to be any real difference between different benzodiazepines in their incidence of side effects outside half life and potency and dose of benzodiazepines.--Literaturegeek | T@1k? 18:20, 19 May 2009 (UTC)

yeah, i meant as a group. anyway, on to FAC after some more sprucing....Casliber (talk · contribs) 21:02, 19 May 2009 (UTC)

Would you like me to apply the frequency of side effects of lorazepam to benzodiazepines as a group? It is difficult to get a source which gives side effects for benzodiazepines as a group let alone incidence of side effects. Believe me I have looked. Most sources saying something like "See under diazepam" or "See under nitrazepam" if looking at a medical text book and online like I said there are few sources which give side effects for benzodiazepines as a group. Side effects are a class effect though.

Ok now for the lead and the history section. I did find some sentences which looked as if they would be better merged, reworked etc so I have made some improvements, at least I hope that they are improvements to those sections. Anything that I am forgetting before we go to featured article candidate? Is it better that I list it as featured article candidate and then you add your name to review it?--Literaturegeek | T@1k? 22:32, 19 May 2009 (UTC)