Table 1.

Evidence to recommendations table: What are the effects of deprescribing BZRAs compared with continuous use in insomnia for adults ≥ 18 y who use BZRAs for insomnia on its own or for comorbid insomnia with underlying comorbidities managed (specifically, adults 18–64 y using BZRAs for most nights of the week for > 4 wk, or adults ≥ 65 y taking BZRAs for any duration as first-line therapy)?

DECISION DOMAIN	SUMMARY OF REASON FOR DECISION	SUBDOMAINS INFLUENCING DECISION
QoE: Is there high- or moderate-quality evidence? Yes □ No ☑	The QoE for the benefits of deprescribing is low to moderate The QoE for the harms of deprescribing is low to moderate	Key reason for downgrading is risk of bias The QoE from RCTs for benefits of deprescribing is low The QoE from RCTs for harms of deprescribing is moderate (sleep quality)
Balance of benefits and harms: Is there certainty that the benefits outweigh the harms? Yes ☑ No □	Effects of interventions on cessation rate Tapering or tapering with CBT improves cessation rates compared with usual care; tapering with CBT improves cessation rates compared with tapering alone postintervention (however, improved rate was not maintained at 3 or 12 mo). Behavioural and educational interventions offered as part of tapering advice Sleep quality outcomes No change in sleep quality with BZRA discontinuation. There was a statistically significant difference in sleep quality with discontinuation of BZRAs compared with continuation of BZRAs at 3 mo in 1 study²⁸ owing to improvement of sleep in the continuation group; however, sleep quality in the taper group was no different than continuation at 52 wk Anxiety There was a small decrease in anxiety reported with deprescribing vs continuation Anxiety might improve within 1 y following deprescribing compared with continuation²⁸ Other harms of deprescribing (eg, adverse drug withdrawal effects) No difference in withdrawal symptoms (BWSQ score) when discontinuing BZRAs compared with continuation of BZRAs or usual care Effect of deprescribing on cognition No significant effect noted in controlled trials at 12 mo Adverse events for the elderly Adverse events for the elderly associated with long-term continued use of BZRAs were also identified: observational evidence shows increased fractures, motor vehicle accidents, functional impairment, respiratory exacerbations (COPD or pneumonia), and memory disturbance	Is the baseline risk of benefit of deprescribing similar across subgroups? Yes ☑ No □ There is no evidence at this time to suggest different subgroups benefit from deprescribing Should there be separate recommendations for subgroups based on risk levels? Yes □ No ☑ There is no evidence of benefit for any risk level Is the baseline risk of harm of deprescribing similar across subgroups? Yes ☑ No □ There is no evidence that harms of deprescribing differ based on subgroup Should there be separate recommendations for subgroups based on harms of continued use? Yes ☑ No □ Observational evidence shows risk of harm associated with continued use of BZRAs in older persons Baseline risk of adverse events with continued BZRA use might be higher for older persons vs younger adults (very low-quality evidence) Harms from deprescribing are low and not different between groups
Values and preferences: Is there confidence in the estimate of relative importance of outcomes and patient preferences? Yes □ No ☑	Patients tend to rate the benefits of BZDs higher than physicians do and rate the risks lower. Those patients interested in stopping BZDs see potential improvements in thinking and memory as benefits, as well as obtaining more natural sleep and feeling proud of themselves for having stopped. Factors associated with increased likelihood of stopping BZRA use include higher education level, lower intake or potency of BZDs, and lower anxiety sensitivity scores. Of those who fail BZD discontinuation, many describe having experienced such failure as difficulty in sleeping within a few days of stopping	Perspective taken: Evidence suggests there are patients who wish to discontinue BZRAs to avoid the harms of long-term use. There are others who might be hesitant and might fail owing to difficulty sleeping after stopping Source of values and preferences: Scoping review on subjects including the elderly Source of variability, if any: Education levels, potency of BZRA, and anxiety sensitivity scores Method for determining values satisfactory for this recommendation? Yes ☑ No □ All critical outcomes measured? Yes ☑ No □
Resource implications: Are the resources worth the expected net benefit? Yes ☑ No □	Cost implications The Canadian Rx Atlas²⁹ reports that the average Canadian aged ≥ 65 y spends $26 annually on a BZD or z drug. In Holland, tapering alone produced significantly more abstinence vs usual care and with cost benefits (36% vs 15%, NNT = 4.8; P = .03) Cost-effectiveness studies showed deprescribing led to a reduction in the medication and related costs and adverse events Physician implications Physicians often anticipate difficulty persuading patients to stop BZDs, concerned about their own workload and how patients will react to being encouraged to stop	Feasibility: Is tapering BZRA intervention generally available? Yes ☑ No □ Deprescribing readily available but CBT less so (owing to cost and access concerns; online CBT is available) Opportunity cost: Is this intervention and its effects worth withdrawing or not allocating resources from other interventions? Yes ☑ No □ Economic and preventive benefits for harms: Is there a lot of variability in resource requirements across settings? Yes □ No ☑ Deprescribing through education and tapering was believed to be a low-resource intervention, feasible for primary and long-term care. Studies suggest follow-up medical visits might be needed during tapering. The addition of CBT to tapering increases the cost
Overall strength of recommendation in older persons (≥ 65 y): strong Overall strength of recommendation in adults < 65 y: weak	There is low-quality evidence that deprescribing interventions improve cessation rates of BZRAs at 3 mo. Compared with continuation of BZRAs, tapering these drugs does not result in any difference in withdrawal symptom scores (low-quality evidence). Those who taper BZRAs might have more problems sleeping than those who continue; however, there is no difference at 12 mo (very low-quality evidence). Our systematic review found that deprescribing of BZRAs did not worsen anxiety. Despite low-quality evidence surrounding deprescribing, our recommendation was rated as strong in older persons owing to evidence surrounding harms of continued BZRA use specifically in older persons (associated increased risk of falls, cognitive impairment, motor vehicle accidents) and resultant resource implications. We also considered literature on patient preferences suggesting patients might value regaining control over sleep and potentially avoiding adverse effects of BZRAs

BWSQ—benzodiazepine withdrawal symptom questionnaire, BZD—benzodiazepine, BZRA—benzodiazepine receptor agonist, CBT—cognitive-behavioural therapy, COPD—chronic obstructive pulmonary disease, NNT—number needed to treat, QoE—quality of evidence, RCT—randomized controlled trial.