Nitrazepam

• Approved Uses:
• Short-term management of insomnia characterized by difficulty initiating or maintaining sleep.
• Treatment of certain epileptic seizures, including absence seizures, myoclonic seizures, and Lennox-Gastaut syndrome.
• Adjunct therapy for anxiety disorders and psychomotor agitation.
• Off-label Uses:
• Sedation before surgical or diagnostic procedures.
• Management of night terrors and sleepwalking in selected cases.

• Adults:
• Insomnia: 5–10 mg orally at bedtime.
• Epilepsy: 5–20 mg daily divided in 1–3 doses based on seizure type.
• Elderly or Debilitated Patients:
• Start with 2.5–5 mg at bedtime, with cautious titration.
• Pediatrics:
• Use cautiously; dosing individualized and generally lower than adults.
• Patients with Hepatic or Renal Impairment:
• Dose adjustments required; initiate at lower doses due to slower metabolism.
• Route: Oral administration.
• Duration: Limited to short-term use for insomnia (typically 2–4 weeks). Longer duration for epilepsy under specialist supervision.

Nitrazepam acts by potentiating the inhibitory neurotransmitter GABA at the GABA-A receptor complex. It enhances GABA-induced chloride ion influx into neurons, leading to hyperpolarization and decreased neuronal excitability, which manifests as sedative, anxiolytic, muscle relaxant, and anticonvulsant effects.

• Absorption: Rapid and nearly complete from the gastrointestinal tract.
• Bioavailability: Approximately 90%.
• Time to Peak Concentration: 1 to 4 hours.
• Distribution: Widely distributed; crosses blood-brain barrier effectively.
• Protein Binding: ~85%.
• Metabolism: Extensively metabolized in the liver via nitroreduction and hydroxylation.
• Half-life: 15 to 38 hours.
• Excretion: Primarily renal, mostly as metabolites.

• Pregnancy: FDA Category D — associated with potential teratogenic effects and neonatal withdrawal symptoms. Use only if benefits justify risks.
• Lactation: Excreted in breast milk; may cause sedation or respiratory depression in nursing infants. Breastfeeding is generally not recommended during therapy.

• Primary Class: Benzodiazepine
• Subclass: Hypnotic, anxiolytic, anticonvulsant

• Hypersensitivity to nitrazepam or other benzodiazepines.
• Severe respiratory insufficiency.
• Severe hepatic impairment.
• Sleep apnea syndrome.
• Myasthenia gravis.
• Acute narrow-angle glaucoma.
• Concurrent use with opioids unless closely monitored.

• Risk of dependence, tolerance, and withdrawal; use minimal effective dose for shortest duration.
• Increased risk of sedation, cognitive impairment, and falls in elderly patients.
• Possible paradoxical reactions such as agitation, aggression, or hallucinations.
• Avoid abrupt discontinuation to prevent rebound insomnia and seizures.
• Caution in patients with depression or suicidal ideation.
• Monitor liver function in prolonged use.
• Use caution in respiratory disorders due to risk of respiratory depression.

• Common: Drowsiness, sedation, dizziness, muscle weakness, fatigue.
• Psychiatric: Confusion, memory impairment, irritability.
• Gastrointestinal: Nausea, dry mouth.
• Serious but rare: Paradoxical reactions, respiratory depression, allergic reactions (rash, angioedema), dependence.

• Additive CNS depression with alcohol, opioids, barbiturates, and other sedatives.
• Metabolized by hepatic enzymes; CYP inducers (e.g., rifampin) can reduce effect; inhibitors (e.g., cimetidine) can increase plasma levels.
• Potentiates effects of muscle relaxants and other anticonvulsants.
• Avoid concomitant use with other CNS depressants unless medically necessary and closely monitored.

• Guidelines emphasize limiting benzodiazepine use for insomnia to short periods (2–4 weeks).
• Increased warnings on use in elderly to prevent falls and cognitive decline.
• Regulatory emphasis on careful tapering to avoid withdrawal symptoms.
• Pediatric use limited to specific seizure disorders under specialist care.

• Store at 20°C to 25°C (68°F to 77°F).
• Protect from moisture and light.
• Keep container tightly closed.
• Keep out of reach of children.
• No refrigeration or special handling required.