Weaning Guidelines
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Table 6: OPIOID/BENZODIAZEPINE TAPER GUIDELINES Indications
Patients who have received an opioid or benzodiazepine frequently over > 5-10
Withdrawal Symptoms
days. Patients at highest risk include those on high dose opioid/benzodiazepine therapy, ICU LOS > 7 days, on prolonged mechanical ventilation. Neurological excitability: irritability, tremors, seizures, increased motor tone, insomnia, encephalopathy GI dysfunction: N/V, diarrhea, cramps Autonomic dysfunction: tachycardia, hypertension, tachypnea, sweating, chills, piloerection, nasal congestion
Opioid/ Benzodiazepine Taper
Treatment of withdrawal symptoms during taper
Streamline regimen/convert polypharmacy • Consider ease of administration, duration of action (long acting preferred), and practicality of tapering the dose when determining which medications/dosage forms to use. • Convert multiple drugs within a family to a single drug in that family using equianalgesic conversions. Consider a 25% opioid dose reduction to compensate for incomplete cross-tolerance. Exception: When converting from another opioid to methadone, consider a 50 to 75% dose reduction. • Convert continous infusion to intermittent dose of longer acting agents adminstered q 4-6 hr around the clock. Administer calculated conversion dose for 24-48 hours, assessing for withdrawal symptoms/side effects and adjusting dose based on patient response. Assess for/document withdrawal symptoms using a reliable, valid tool on a routine basis (ie., prior to medication administration) and prn. Report/treat withdrawal symptoms during conversion/taper 24 to 48 hours after optimal dose determined, begin taper Decrease dose 10-20% /day (5-15%/day for high risk patients). Calculate dose based on previous day’s dose. Consider increasing time interval between medication doses after taper is halfway completed (ie., ↑ dosing interval from q 4 hr., to q 6hr., then to q 8 hr. Discontinue taper when dose and frequency is neglible Stop taper and resume previous dose. Resume taper after 24 hours has elapsed without withdrawal symptoms. Consider clonidine to ameliorate withdrawal symptoms.
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Patients who have received an opioid or benzodiazepine frequently over > 5-10
Withdrawal Symptoms
days. Patients at highest risk include those on high dose opioid/benzodiazepine therapy, ICU LOS > 7 days, on prolonged mechanical ventilation. Neurological excitability: irritability, tremors, seizures, increased motor tone, insomnia, encephalopathy GI dysfunction: N/V, diarrhea, cramps Autonomic dysfunction: tachycardia, hypertension, tachypnea, sweating, chills, piloerection, nasal congestion
Opioid/ Benzodiazepine Taper
Treatment of withdrawal symptoms during taper
Streamline regimen/convert polypharmacy • Consider ease of administration, duration of action (long acting preferred), and practicality of tapering the dose when determining which medications/dosage forms to use. • Convert multiple drugs within a family to a single drug in that family using equianalgesic conversions. Consider a 25% opioid dose reduction to compensate for incomplete cross-tolerance. Exception: When converting from another opioid to methadone, consider a 50 to 75% dose reduction. • Convert continous infusion to intermittent dose of longer acting agents adminstered q 4-6 hr around the clock. Administer calculated conversion dose for 24-48 hours, assessing for withdrawal symptoms/side effects and adjusting dose based on patient response. Assess for/document withdrawal symptoms using a reliable, valid tool on a routine basis (ie., prior to medication administration) and prn. Report/treat withdrawal symptoms during conversion/taper 24 to 48 hours after optimal dose determined, begin taper Decrease dose 10-20% /day (5-15%/day for high risk patients). Calculate dose based on previous day’s dose. Consider increasing time interval between medication doses after taper is halfway completed (ie., ↑ dosing interval from q 4 hr., to q 6hr., then to q 8 hr. Discontinue taper when dose and frequency is neglible Stop taper and resume previous dose. Resume taper after 24 hours has elapsed without withdrawal symptoms. Consider clonidine to ameliorate withdrawal symptoms.
/var/www/apps/pdfcoke/pdfcoke/tmp/scratch3/10058060.doc 5/28/02
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