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Response to Understanding Benzodiazepine-Induced Balance Impairment- A Case Study Analysis

Response to Understanding Benzodiazepine-Induced Balance Impairment- A Case Study Analysis

Responding to Sherria Conner

Hello Sherri,

Thanks for your post! It is indeed true that diazepam may cause gait instability. Diazepam, a benzodiazepine, has the side effects of CNS depression, with subsequent manifestations of drowsiness and dizziness. These side effects are more profound in the elderly population. The patient, in this case, is likely to have experienced CNS depression resulting in gait instability.

The first-pass effect defines the pharmacological process in which a drug undergoes metabolism at specific locations. While your definition of the same is accurate, it could also mention that the first-pass effect can occur at varied sites such as the liver, lungs, and other metabolically active tissues (Khalid et al., 2021). Diazepam experiences a significant first-pass effect. Circumventing the first-pass effect may be necessary for dose optimization. This can be attained by using alternative routes, such as intravenous and intramuscular routes. Intramuscular and intravenous formulations of diazepam exist. Confusion apparent in the case presented can be attributable to the medications the patient took. Confusion is a notable side effect of first-generation antihistamines such as diphenhydramine. Older patients have also been shown to be sensitive towards phenylephrine, with confusion occurring in a large proportion of older patients taking this medication (Alpay et al., 2019). Taking diphenhydramine and phenylephrine concomitantly may thus result in profound confusion.

Warfarin, an oral anticoagulant, is metabolized by the CYP2C9 subset of the microsomal enzymes. It crosses the placental barriers and has been associated with teratogenicity. The hepatic drug metabolism of neonates differs from that of other populations. In neonates, the metabolizing enzymes have yet to develop fully (Konstandi & Johnson, 2023). Persons in this group thus have reduced metabolizing capacity for xenobiotics. As one develops, their metabolizing capacity increases as the microsomal enzymes also develop. Neonatal protein binding is also low. This is due to the lower concentration of albumin and other protein binders due to the higher body water percentage of neonates.


Khalid, S., Rasool, M. F., Imran, I., Majeed, A., Saeed, H., Rehman, A. ur, Ashraf, W., Ahmad, T., Bin Jardan, Y. A., & Alqahtani, F. (2021). A physiologically based pharmacokinetic model for predicting diazepam pharmacokinetics after intravenous, oral, intranasal, and rectal applications. Pharmaceutics, 13(9), 1480.

Alpay, A., Canturk Ugurbas, S., & Aydemir, C. (2019). Efficiency and safety of phenylephrine and tropicamide used in premature retinopathy: A prospective observational study. BMC Pediatrics, 19(1).

Konstandi, M., & Johnson, E. O. (2023). Age-related modifications in CYP-dependent drug metabolism: Role of stress. Frontiers in Endocrinology, 14.


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Explain the cause of this patient’s difficulty in maintaining her balance. Valium is a drug that is categorized as a benzodiazepine, with adverse effects including psychomotor impairment, the slowing of a person’s reaction time, unwanted sedation, and memory impairment (Greenblatt et al., 2020). Due to increasing age, the patient has the potential to become increasingly sensitive to drugs that are central nervous system depressants, such as Valium,

Response to Understanding Benzodiazepine-Induced Balance Impairment- A Case Study Analysis

Response to Understanding Benzodiazepine-Induced Balance Impairment- A Case Study Analysis

even if the patient has been taking the drug over an extended period of time. According to Greenblatt et al., the aging process has predictable outcomes, such as the loss of lean body mass in relation to total weight and the increase of adipose tissue, especially in women, along with the decrease in drug-metabolizing capacity, means that elderly women population have consistently higher levels of drug distribution of valium than any other group, as valium is a lipophilic drug (2020).

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