A DOCS Education Member writes:
I have a 32-year-old patient that uses fluticasone 50 mg nasal spray, is on birth control depot and takes 0.5 mg triazolam daily at bedtime. She consumes 4 large cups of coffee each day. What protocol would you recommend for oral sedation?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
This case could be a challenge due to the tolerance the patient has built up to 0.5 mg doses of triazolam. In addition, the patient is accustomed to regular doses of caffeine. The only things that would make this case tougher would be if the patient smokes and is petite.
A test sedation appointment is appropriate here. A single-dose protocol will not work in this case. If this case has any chance of success, you need the capability to dose incrementally to effect. I would not have the patient take any diazepam the night before. Allow her to take the regular dose of triazolam at bedtime. On the morning of the appointment, I would allow the patient to have up to 1/2 cup of coffee.
The patient should take a loading dose of 0.25 mg triazolam, and you should assess upon arrival for the appropriate dose of triazolam. I wouldn't be surprised if your assessment determines that the patient will need doses as high as 0.5 mg, but follow the DOCS Education assessment criteria. Do not exceed TOP Dose for the patient.
Your patient would also benefit from 50-100 mg of hydroxyzine in a single dose. If TOP Dose is reached and the patient is not comfortable, then she is a better candidate for IV sedation.
FOLLOW UP: DOCS Member writes:
Unfortunately this goes back 10-15 years, but isn't chronic use of triazolam contraindicated because of interference of REM sleep cycles? Can't use of this medication over a long period (weeks or months) actually cause symptoms consistent with sleep deprivation of some degree?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Triazolam has been shown to cause hallucinations, paranoia and depression with extended use. Of course, this doesn't happen with everyone and is most likely seen in patients prone to these reactions. This patients seems to tolerate the extended use of triazolam.
Triazolam's chronic use has been curtailed significantly since FDA prescribing and dispensing regulations have limited the amount of triazolam tablets dispensed to ten and have eliminated refills.
