Side Effects of Halcion (triazolam)

Halcion (triazolam) is a benzodiazepine used to promote sleep in individuals who have difficulty sleeping (insomnia). 

Insomnia is believed often to be the result of anxiety, a state in which the brain is excessively active. Gamma-aminobutyric acid (GABA) is a substance produced in the brain which inhibits (slows down) nerves and many of the activities of the brain.

Halcion and other benzodiazepines enhance the effects of GABA and thereby reduce activity in the brain and promote sleep. 

Common side effects of Halcion include:

• weakness or tiredness,
• dizziness,
• drowsiness,
• clumsiness, and
• unsteadiness.

Other side effects of Halcion include:

• "hangover" effects,
• headache,
• increased dreaming,
• memory loss,
• nausea,
• vomiting,
• confusion,
• depression,
• lightheadedness or fainting spells,
• mood changes,
• excitability,
• aggressive behavior,
• movement difficulty,
• staggering or jerky movements,
• muscle cramps, and
• tremors.

Drug interactions of Halcion include other drugs that also inhibit activity within the brain, such as:

• alcohol,
• barbiturates narcotics, and
• some over-the-counter antihistamines, which when combined with Halcion may cause excessive sedation.

Some drugs raising the levels of Halcion in the body and cause excessive sedation, including:

• cimetidine,
• some macrolide antibiotics,
• azole antifungals,
• telaprevir,
• nelfinavir,
• fluvoxamine, and
• grapefruit juice.

The following drugs can lead to a loss of Halcion's effectiveness:

• phenytoin,
• carbamazepine,
• rifampin, and
• rifabutin.

Halcion is contraindicated during pregnancy because benzodiazepines are associated with fetal abnormalities when used during pregnancy.

It is unknown if Halcion is secreted into human breast milk. Other benzodiazepines are and it is likely Halcion is as well. Halcion should be avoided while breastfeeding.

The most common side effects of triazolam are:

• weakness or tiredness,
• dizziness,
• drowsiness,
• clumsiness, or
• unsteadiness.

Other side effects include:

• "hangover" effects,
• headache,
• increased dreaming,
• loss of memory,
• nausea,
• vomiting,
• confusion,
• depression,
• lightheadedness or fainting spells,
• mood changes,
• excitability,
• aggressive behavior,
• movement difficulty,
• staggering or jerky movements,
• muscle cramps, and
• tremors.

• During placebo-controlled clinical studies in which 1,003 patients received Halcion Tablets, the most troublesome side effects were extensions of the pharmacologic activity of triazolam, eg, drowsiness, dizziness, or light-headedness.
• The figures cited below are estimates of untoward clinical event incidence among subjects who participated in the relatively short duration (i.e., 1 to 42 days) placebo-controlled clinical trials of Halcion.
• The figures cannot be used to predict precisely the incidence of untoward events in the course of usual medical practice where patient characteristics and other factors often differ from those in clinical trials.
• These figures cannot be compared with those obtained from other clinical studies involving related drug products and placebo, as each group of drug trials is conducted under a different set of conditions.
• Comparison of the cited figures, however, can provide the prescriber with some basis for estimating the relative contributions of drug and nondrug factors to the untoward event incidence rate in the population studied.
• Even this use must be approached cautiously, as a drug may relieve a symptom in one patient while inducing it in others. (For example, an anticholinergic, anxiolytic drug may relieve dry mouth [a sign of anxiety] in some subjects but induce it [an untoward event] in others.)

In addition to the relatively common (i.e., 1% or greater) untoward events enumerated above, the following adverse events have been reported less frequently (i.e., 0.9% to0.5%):

• euphoria,
• tachycardia,
• tiredness,
• confusional states/memory impairment,
• cramps/pain,
• depression,
• visual disturbances.

Rare (i.e., less than 0.5%) adverse reactions included:

• constipation,
• taste alterations,
• diarrhea,
• dry mouth,
• dermatitis/allergy,
• dreaming/nightmares,
• insomnia,
• paresthesia,
• tinnitus,
• dysesthesia,
• weakness,
• congestion,
• death from hepatic failure in a patient also receiving diuretic drugs.

In addition to these untoward events for which estimates of incidence are available, the following adverse events have been reported in association with the use of Halcion and other benzodiazepines:

• amnestic symptoms (anterograde amnesia with appropriate or inappropriate behavior),
• confusional states (disorientation, derealization, depersonalization, and/or clouding of consciousness),
• dystonia,
• anorexia,
• fatigue,
• sedation,
• slurred speech,
• jaundice,
• pruritus,
• dysarthria,
• changes in libido,
• menstrual irregularities,
• incontinence, and
• urinary retention.

Other factors may contribute to some of these reactions, eg, concomitant intake of alcohol or other drugs, sleep deprivation, an abnormal premorbid state, etc.

Other events reported include:

• paradoxical reactions such as stimulation,
• mania,
• an agitational state (restlessness, irritability, and excitation),
• increased muscle spasticity,
• sleep disturbances,
• hallucinations,
• delusions,
• aggressiveness,
• falling,
• somnambulism,
• syncope,
• inappropriate behavior and
• other adverse behavioral effects.

Should these occur, use of the drug should be discontinued.

The following events have also been reported:

• chest pain,
• burning tongue/glossitis/stomatitis.

Laboratory analyses were performed on all patients participating in the clinical program for Halcion. The following incidences of abnormalities were observed in patients receiving Halcion and the corresponding placebo group. None of these changes were considered to be of physiological significance.

When treatment with Halcion is protracted, periodic blood counts, urinalysis, and blood chemistry analyses are advisable.

Minor changes in EEG patterns, usually low-voltage fast activity, have been observed in patients during therapy with Halcion and are of no known significance.

Drug Abuse And Dependence

• Abuse and addiction are separate and distinct from physical dependence and tolerance. Abuse is characterized by misuse of the drug for non-medical purposes, often in combination with other psychoactive substances.
• Physical dependence is a state of adaptation that is manifested by a specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist.
• Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. Tolerance may occur to both the desired and undesired effects of drugs and may develop at different rates for different effects.
• Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
• Drug addiction is a treatable disease, utilizing a multidisciplinary approach, but relapse is common.

Controlled Substance

• Triazolam is a controlled substance under the Controlled Substance Act, and Halcion Tablets have been assigned to Schedule IV.

Abuse, Dependence And Withdrawal

• Withdrawal symptoms, similar in character to those noted with barbiturates and alcohol (convulsions, tremor, abdominal and muscle cramps, vomiting, sweating, dysphoria, perceptual disturbances and insomnia), have occurred following abrupt discontinuance of benzodiazepines, including Halcion.
• The more severe symptoms are usually associated with higher dosages and longer usage, although patients at therapeutic dosages given for as few as 1-2 weeks can also have withdrawal symptoms and in some patients there may be withdrawal symptoms (daytime anxiety, agitation) between nightly doses.
• Consequently, abrupt discontinuation should be avoided and a gradual dosage tapering schedule is recommended in any patient taking more than the lowest dose for more than a few weeks.
• The recommendation for tapering is particularly important in any patient with a history of seizure.
• The risk of dependence is increased in patients with a history of alcoholism, drug abuse, or in patients with marked personality disorders.
• Such dependence-prone individuals should be under careful surveillance when receiving Halcion.
• As with all hypnotics, repeat prescriptions should be limited to those who are under medical supervision.

• The concomitant use of benzodiazepines and opioids increases the risk of respiratory depression because of actions at different receptor sites in the CNS that control respiration.
• Benzodiazepines interact at GABA sites and opioids interact primarily at mu receptors. When benzodiazepines and opioids are combined, the potential for benzodiazepines to significantly worsen opioid-related respiratory depression exists. Limit dosage and duration of concomitant use of benzodiazepines and opioids, and monitor patients closely for respiratory depression and sedation.
• Both pharmacodynamic and pharmacokinetic interactions have been reported with benzodiazepines.
• In particular, triazolam produces additive CNS depressant effects when coadministered with:
  • other psychotropic medications,
  • anticonvulsants,
  • antihistamines,
  • ethanol, and
  • other drugs which themselves produce CNS depression.

Drugs that inhibit triazolam metabolism via cytochrome P450 3A

• The initial step in triazolam metabolism is hydroxylation catalyzed by cytochrome P450 3A (CYP 3A). Drugs which inhibit this metabolic pathway may have a profound effect on the clearance of triazolam.
• Halcion is contraindicated with:
  • ketoconzaole,
  • itraconazole,
  • nefazodone, and
  • several HIV protease inhibitors.
• Drugs and other substances demonstrated to be CYP 3A inhibitors of possible clinical significance on the basis of clinical studies involving triazolam (caution is recommended during coadministration with triazolam)

Isoniazid

• Coadministration of isoniazid increased the maximum plasma concentration of triazolam by 20%, decreased clearance by 42%, and increased half-life by 31%.

Oral Contraceptives

• Coadministration of oral contraceptives increased maximum plasma concentration by 6%, decreased clearance by 32%, and increased half-life by 16%.

Grapefruit Juice

• Coadministration of grapefruit juice increased the maximum plasma concentration of triazolam by 25%, increased the area under the concentration curve by 48%, and increased half-life by 18%.
• Drugs demonstrated to be CYP 3A inhibitors on the basis of clinical studies involving benzodiazepines metabolized similarly to triazolam or on the basis of in vitro studies with triazolam or other benzodiazepines (caution is recommended during coadministration with triazolam)
• Available data from clinical studies of benzodiazepines other than triazolam suggest a possible drug interaction with triazolam for the following:
  • fluvoxamine,
  • diltiazem, and
  • verapamil.
• Data from in vitro studies of triazolam suggest a possible drug interaction with triazolam for the following:
  • sertraline and paroxetine.
• Data from in vitro studies of benzodiazepines other than triazolam suggest a possible drug interaction with triazolam for the following:
  • ergotamine,
  • cyclosporine,
  • amiodarone,
  • nicardipine, and
  • nifedipine.
• Caution is recommended during coadministration of any of these drugs with triazolam.
• Drugs that affect triazolam pharmacokinetics by other mechanisms

Ranitidine

• Coadministration of ranitidine increased the maximum plasma concentration of triazolam by 30%, increased the area under the concentration curve by 27%, and increased half-life by 3.3%.
• Caution is recommended during coadministration with triazolam.