Flurazepam (Monograph)

Brand name: Formerly available as Dalmane
Drug class: Benzodiazepines
VA class: CN302
CAS number: 1172-18-5

Medically reviewed by Drugs.com on Sep 26, 2022. Written by ASHP.

Warning

Concomitant use of benzodiazepines and opiates may result in profound sedation, respiratory depression, coma, and death.⁷⁰⁰ ⁷⁰¹ ⁷⁰³ ⁷⁰⁵ ⁷⁰⁶ ⁷⁰⁷
Reserve concomitant use for patients in whom alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy and monitor closely for respiratory depression and sedation.⁷⁰⁰ ⁷⁰³ (See Specific Drugs under Interactions.)

A boxed warning has been included in the prescribing information for all benzodiazepines describing risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions.⁹⁰⁰
Abuse and misuse can result in overdose or death, especially when benzodiazepines are combined with other medicines, such as opioid pain relievers, alcohol, or illicit drugs.⁹⁰⁰
Assess a patient’s risk of abuse, misuse, and addiction.⁹⁰⁰ Standardized screening tools are available ([Web]).⁹⁰⁰
To reduce risk of acute withdrawal reactions, use a gradual dose taper when reducing dosage or discontinuing benzodiazepines.⁹⁰⁰ Take precautions when benzodiazepines are used in combination with opioid medications.⁹⁰⁰

Introduction

Benzodiazepine; sedative and hypnotic.^a ^b ^d

Uses for Flurazepam

Insomnia

Short-term management of insomnia.^a ^d Has been used effectively for periods up to 4 weeks in duration.^a ^b ^d

Has been used effectively in individuals with difficulty in falling asleep, nocturnal awakenings, and/or early morning awakening.^d

May exhibit carryover effect (i.e., more effective on second, third, and fourth nights of use than on first night) because of accumulation of active metabolite.^b ^d Effect may persist on first and sometimes second night after discontinuance.^b ^d

Because of long half-life, may be more likely to result in residual sedative effects and in impaired psychomotor and mental performance during continued therapy, although partial tolerance to these effects can occur.²⁰⁷ ²¹⁵ ²¹⁶ ²¹⁷ ²¹⁸ ²¹⁹ ²⁴⁵ ²⁵² ²⁵⁴ ²⁵⁹ ²⁶² ²⁶⁴ ²⁶⁷ ²⁹⁸ ³¹¹ ³¹² ³¹³ ³¹⁷ ³²¹ ³²² ³²³ ³³⁷ ³³⁸ ³⁴⁴ ³⁴⁶ ³⁴⁸ ³⁵³ Differences among hypnotics in residual and cumulative CNS depressant effects may be particularly important in geriatric patients,²¹⁵ ²¹⁷ ²²¹ ²²² ²²⁴ ²³⁵ ²⁵² ²⁵³ ²⁵⁹ ²⁶⁹ ²⁷⁶ ²⁹⁷ ³¹² ³¹³ ³¹⁷ ³¹⁸ ³¹⁹ ³²⁵ ³⁵⁶ ³⁷² ³⁷⁷ those with potentially impaired elimination of the drugs, and those whose job or life-style requires unimpaired intellectual or psychomotor function.²¹⁵ ²¹⁷ ²¹⁸ ²⁵⁷ ²⁷⁰ ²⁷⁹ ²⁸⁰ ²⁹⁷ ²⁹⁸

Flurazepam Dosage and Administration

General

Use hypnotics only when able to get a full night’s sleep before being active again.^e
Use the smallest effective dose (especially in geriatric or debilitated patients and in those with liver disease or low serum albumin).^a ^b ^d
Avoid prolonged administration.^a ^d
Reevaluate patient’s condition if hypnotic use exceeds 2–3 weeks.²⁰⁷
Avoid abrupt discontinuance in patients who have received prolonged therapy (e.g., several months) because of potential for precipitating withdrawal manifestations.^a ^b ^d Gradually taper dosage.^a ^d

Administration

Oral Administration

Administer at bedtime.^a ^d

Dosage

Available as flurazepam hydrochloride; dosage expressed in terms of the salt.^d

Adults

Insomnia

Oral

Usual dosage is 30 mg at bedtime.^a ^d In some patients, 15 mg may be adequate.^a ^d

Special Populations

Hepatic Impairment

Reduce dosage.^b Use smallest effective dosage.^a

Renal Impairment

No specific dosage recommendations.^d

Geriatric or Debilitated Patients

Initial dose of 15 mg at bedtime.^a ^d Use smallest effective dosage.^a

Cautions for Flurazepam

Contraindications

Known hypersensitivity to flurazepam.^d
Pregnancy.^b ^d
Many manufacturers state that benzodiazepines are contraindicated in patients with acute angle-closure glaucoma (but may be administered to patients with open-angle glaucoma receiving appropriate therapy); however, clinical rationale for this contraindication has been questioned.^b

Warnings/Precautions

Warnings

Concomitant Use with Opiates

Concomitant use of benzodiazepines, including flurazepam, and opiates may result in profound sedation, respiratory depression, coma, and death.⁷⁰⁰ ⁷⁰¹ ⁷⁰³ ⁷⁰⁵ ⁷⁰⁶ ⁷⁰⁷ Substantial proportion of fatal opiate overdoses involve concurrent benzodiazepine use.⁷⁰⁰ ⁷⁰¹ ⁷⁰⁵ ⁷⁰⁶ ⁷⁰⁷ ⁷¹¹

Reserve concomitant use of flurazepam and opiates for patients in whom alternative treatment options are inadequate.⁷⁰⁰ ⁷⁰³ (See Specific Drugs under Interactions.)

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm; avoid use of benzodiazepines as hypnotics during pregnancy.^b ^d If used during pregnancy or if patient becomes pregnant, apprise of potential fetal hazard.^d

Adequate Patient Evaluation

Insomnia may be a manifestation of an underlying physical and/or psychiatric disorder; carefully evaluate patient before providing symptomatic treatment.^a ^d

Failure of insomnia to remit after 7–10 days of treatment, worsening of insomnia, or emergence of new abnormal thinking or behavior may indicate the presence of an underlying psychiatric and/or medical condition.^d

Complex Sleep-related Behaviors

Potential risk of complex sleep-related behaviors such as sleep-driving (i.e., driving while not fully awake after ingesting a sedative-hypnotic drug with no memory of the event), making phone calls, or preparing and eating food, while asleep. ⁶²⁹ ^d

Adverse Psychiatric Events

Abnormal thinking and behavioral changes (e.g., aggressiveness, uncharacteristic extroversion, bizarre behavior, agitation, hallucinations, depersonalization, amnesia) may occur in patients receiving benzodiazepines.²⁰⁷ ²⁵⁸ ²⁶² ²⁶⁹ ²⁸⁴ ²⁸⁵ ²⁸⁶ ²⁸⁷ ²⁹⁷ ³⁷² ⁴⁸⁸

Immediately evaluate any new behavioral sign or symptom.²⁰⁷

CNS Depression

Performance of activities requiring mental alertness and physical coordination may be impaired.^b ^d

Concurrent use of other CNS depressants may cause additive or potentiated CNS depression.^b ^d (See Concomitant Use with Opiates under Cautions and also see Specific Drugs under Interactions.)

Dependence and Abuse Potential

Psychologic and physical dependence may occur following prolonged use.^b ^d

Patients with a history of drug or alcohol dependence or abuse are at risk of habituation or dependence; use only with careful surveillance in such patients.^d

Tolerance and Withdrawal Effects

Tolerance may occur following prolonged benzodiazepine use.^b

Abrupt discontinuance may result in symptoms of withdrawal (similar to barbiturates or alcohol).^b ^d

Sensitivity Reactions

Potential risk of anaphylaxis and angioedema; may occur even with the first dose of drug.⁶²⁹ ^d

General Precautions

Suicide

Use with caution in depressed patients; potential for suicidal tendencies.^d Prescribe and dispense drug in the smallest feasible quantity.^b

Respiratory Effects

Use with caution in patients with compromised pulmonary function.^b ^d

Specific Populations

Pregnancy

Category X.^c (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

If used during the last weeks of pregnancy, potential for neonatal CNS depression.^c ^d

Lactation

Benzodiazepines generally are distributed into milk;^b not known whether flurazepam is distributed into milk, but distribution into milk should be expected.^c

Pediatric Use

Safety and efficacy not established in children <15 years of age.^a ^d

Geriatric Use

Potential increased sensitivity (increased risk of oversedation, dizziness, confusion, and/or ataxia);^b ^d use low initial dose and monitor closely.²⁰⁷ ²²¹ ²²⁴ ^b ^d

Half-life of desalkylflurazepam is prolonged following multiple doses in geriatric men and women and after single-dose administration in geriatric men.^d

Hepatic Impairment

Use with caution.^b ^d Use reduced dosage.^b

Renal Impairment

Use with caution.^b ^d

Common Adverse Effects

Dizziness,^d drowsiness,^d lightheadedness,^d staggering,^d ataxia,^d falling^d (particularly in geriatric or debilitated patients).^d

Drug Interactions

Specific Drugs

Drug	Interaction	Comments
Cimetidine	Possible decreased plasma clearance of flurazepam²⁰⁰ ⁶²⁵	Use with caution; consider flurazepam dosage reduction²⁰⁰ ³⁷² ⁶¹⁰
Clozapine	Severe hypotension, respiratory or cardiac arrest, and loss of consciousness reported when benzodiazepines (including flurazepam) were given with or within 24 hours before clozapine⁵²⁹ ⁵⁹¹ ⁵⁹² ⁵⁹³ ⁵⁹⁵ ⁵⁹⁷ ⁵⁹⁸ ⁶⁰⁰	Use with caution⁴³⁵ ⁵⁹¹ ⁵⁹⁹ Some clinicians recommend discontinuance of benzodiazepine therapy ≥1 week prior to initiation of clozapine⁵⁹⁷ ⁵⁹⁸
CNS depressants (alcohol, anticonvulsants, sedatives)	Additive CNS depressant effects^b ^d	Do not use alcohol concomitantly with hypnotics;⁷⁰⁰ ^e caution if other CNS depressants are used concomitantly with flurazepam^b ^d
Disulfiram	Possible inhibition of flurazepam metabolism²⁰⁰	Observe closely for enhanced benzodiazepine response²⁰⁰ Consider possible need for flurazepam dosage reduction²⁰⁰
Opiate agonists and partial agonists	Risk of profound sedation, respiratory depression, coma, or death⁷⁰⁰ ⁷⁰¹ ⁷⁰³ ⁷⁰⁵ ⁷⁰⁶ ⁷⁰⁷	Whenever possible, avoid concomitant use⁷⁰⁸ ⁷⁰⁹ ⁷¹⁰ ⁷¹¹ Opiate analgesics: Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy; monitor closely for respiratory depression and sedation⁷⁰⁰ ⁷⁰³ In patients receiving flurazepam, initiate opiate analgesic, if required, at reduced dosage and titrate based on clinical response⁷⁰⁰ In patients receiving an opiate analgesic, initiate flurazepam, if required, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response⁷⁰⁰ Opiate antitussives: Avoid concomitant use⁷⁰⁰ ⁷⁰⁴ Consider offering naloxone to patients receiving benzodiazepines and opiates concomitantly⁷⁰⁹ ⁷¹²

Flurazepam Pharmacokinetics

Absorption

Bioavailability

Rapidly absorbed from the GI tract,^b ^d with peak plasma concentration achieved within 30–60 minutes.^d

Onset

Onset of hypnotic effect occurs within 15–45 minutes.^b

Duration

Hypnotic effect persists for 7–8 hours.^b

Distribution

Extent

Benzodiazepines are widely distributed into body tissues and cross the blood-brain barrier.^b

Benzodiazepines and their metabolites generally cross the placenta and are distributed into milk.^b Not known whether flurazepam is distributed into milk, but distribution into milk should be expected.^c

Plasma Protein Binding

Benzodiazepines and their metabolites are highly bound to plasma proteins.^b

Elimination

Metabolism

Undergoes first-pass metabolism in the liver; major metabolites are N-1-desalkylflurazepam and N-1-hydroxyethylflurazepam.^b ^d Hydroxylated metabolite undergoes subsequent conjugation.^b ^d

Elimination Route

Eliminated mainly in the urine; 25–55% of dose recovered as conjugates of N-1-hydroxyethylflurazepam, and <1% recovered as N-1-desalkylflurazepam.^d

Half-life

Flurazepam: 2.3 hours.^d

N-1-Desalkylflurazepam: 47–100 hours.^b ^d

N-1-Hydroxyethylflurazepam: 2–4 hours.^b

Special Populations

Geriatric men: Desalkylflurazepam half-life of 160 or 126 hours (after single or multiple doses, respectively) versus 74 or 111 hours in younger males.^d

Geriatric women: Desalkylflurazepam half-life of 120 or 158 hours (after single or multiple doses, respectively) versus 90 or 113 hours in younger females.^d

In patients with liver disease, elimination half-life may be prolonged.^b

Benzodiazepines are not appreciably removed by hemodialysis.^b

Stability

Storage

Oral

Capsules

25°C (may be exposed to 15–30°C).^d

Actions

Effects appear to be mediated through the inhibitory neurotransmitter GABA; the sites and mechanisms of action within the CNS appear to involve a macromolecular complex (GABA_A-receptor-chloride ionophore complex) that includes GABA_A receptors, high-affinity benzodiazepine receptors, and chloride channels.³¹³ ³²⁰ ³⁵⁸ ³⁵⁹ ³⁶⁰ ³⁶¹ ³⁶² ³⁶³ ³⁶⁴ ³⁶⁵ ³⁶⁶ ³⁶⁷ ³⁶⁸ ³⁶⁹ ³⁷⁰

Advice to Patients

Provide patient with a copy of the manufacturer’s patient information.^e ^f
Risk of potentially fatal additive effects (e.g., profound sedation, respiratory depression, coma) if used concomitantly with opiates either therapeutically or illicitly.⁷⁰⁰ ⁷⁰³ Avoid concomitant use of opiate antitussives;⁷⁰⁰ ⁷⁰⁴ also avoid concomitant use of opiate analgesics unless use is supervised by clinician.⁷⁰⁰ ⁷⁰³
Importance of taking only as prescribed; do not increase dosage or duration of therapy or abruptly discontinue unless otherwise instructed by a clinician.^b ^d
Importance of informing clinicians of any behavioral or mental changes, memory impairment, sleep driving, tolerance, or dependence/withdrawal symptoms.²⁰⁷ ⁴⁷⁰ ⁴⁹¹ ^d
Importance of taking hypnotics only when able to get a full night’s sleep before being active again.^e
Potential for drug to impair mental alertness or physical coordination; avoid driving or operating machinery until effects on individual are known.^b ^d
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and of any concomitant illnesses, particularly depression.^a ^d
Importance of not consuming alcoholic beverages when taking hypnotics.^e
Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed;^d necessity for clinicians to advise women to avoid pregnancy during therapy.^d
Importance of informing patients of other important precautionary information.^d (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Subject to control under the Federal Controlled Substances Act of 1970 as a schedule IV (C-IV) drug.^a ^d

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Flurazepam Hydrochloride
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	Capsules	15 mg*	Flurazepam Hydrochloride Capsules (C-IV)
		30 mg*	Flurazepam Hydrochloride Capsules (C-IV)

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