DIAZEPAM 
Pronounciation
- (dye-AYZ-eh-pam)
Trade Name(s)
- Valium
Dose should be individualized. The usual recommended dose in older pediatric patients and adults is 2 to 20 mg IM or IV depending on the indication and its severity. In some conditions (e.g., tetanus), larger doses may be required. In acute conditions, the injection may be repeated within 1 hour, although an interval of 3 to 4 hours is usually satisfactory. Consider transition to oral therapy, if appropriate, once the acute symptomatology has been controlled.
Moderate anxiety disorders and symptoms of anxiety:
2 to 5 mg IV. Repeat in 3 to 4 hours if necessary.
Severe anxiety disorders and symptoms of anxiety:
5 to 10 mg IV. Repeat in 3 to 4 hours if necessary.
10 mg initially, then 5 to 10 mg in 3 to 4 hours if necessary.
10 mg or less is usually effective given immediately before procedure begins; titrate to desired sedation (e.g., slurred speech). Up to 20 mg may be indicated if a narcotic is not used.
5 to 10 mg. Repeat in 3 to 4 hours if necessary. Larger doses may be required in tetanus.
Status epilepticus and severe recurrent convulsive seizures:
5 to 10 mg. May be repeated at intervals of 10 to 15 minutes up to a total dose of 30 mg. May repeat in 2 to 4 hours. Another source suggests 0.15 to 0.2 mg/kg (maximum dose of 10 mg). May repeat one time.
5 to 15 mg 5 to 10 minutes before procedure begins.
Safety for use in neonates not established but is used. Neonates and young infants have reduced or immature organ function; may be susceptible to prolonged CNS depression. Avoid small veins (e.g., dorsum of hand or wrist); see Monitor. Use in infants and children is most frequent in tetany and status epilepticus. Use of longer-acting anticonvulsants (e.g., phenobarbital, phenytoin) following diazepam may be indicated.
Tetanus in pediatric patients from 30 days of age to 5 years of age:
1 to 2 mg every 3 to 4 hours as necessary. Another source recommends a dose of 0.1 to 0.2 mg/kg/dose every 2 to 6 hours in infants and children, titrating as needed.
Respiratory assistance must be available.
Tetanus in pediatric patients 5 years of age or older:
5 to 10 mg every 3 to 4 hours as necessary. Respiratory assistance must be available.
Status epilepticus in neonates (unlabeled):
0.1 to 0.3 mg/kg/dose given over 3 to 5 minutes, every 15 to 30 minutes, to a maximum total dose of 2 mg (not recommended as first-line agent).
Status epilepticus in pediatric patients from 30 days of age to 5 years of age:
0.2 to 0.5 mg every 2 to 5 minutes to a maximum 5-mg dose. Another source suggests 0.1 to 0.3 mg/kg/dose given over 3 to 5 minutes every 5 to 10 minutes with a maximum dose of 10 mg for pediatric patients over 30 days of age.
Status epilepticus in pediatric patients 5 years of age or older:
1 mg every 2 to 5 minutes to a maximum 10-mg dose. May repeat in 2 to 4 hours if necessary.
Lower doses (usually 2 to 5 mg) with slow titration should be used in elderly or debilitated patients and when other sedative medications are coadministered. ■ See Drug/Lab Interactions.
Do not dilute or mix with any other drug. Should be given directly into the vein. Inject into IV tubing close to vein site only when direct IV injection is not feasible. Consider heparin lock for frequent injection.
Store at CRT in cartons to protect from light. Do not freeze.
Manufacturers recommend not mixing with any other drug or solution in syringe or solution. Precipitation can occur.
Other sources suggest a few specific compatibilities dependent on concentration and manufacturer; consult a pharmacist.
5 mg (1 mL) or fraction thereof over 1 minute. Maximum rate is 5 mg/min.
Infants and other pediatric patients:
Give total dose over a minimum of 3 minutes in a dosage not to exceed 0.25 mg/kg.
A benzodiazepine that binds to benzodiazepine receptors on the postsynaptic GABA neuron. Acts on parts of the limbic system, the thalamus and the hypothalamus, and induces calming effects. Exerts antianxiety, sedative/hypnotic, amnesic, anticonvulsant, skeletal muscle relaxant, and antitremor effects. Diminishes patient recall. Metabolized in the liver; stays in the body in appreciable amounts for several days and is excreted very slowly in the urine. Crosses the placental barrier. Secreted in breast milk.
Relief of acute anxiety when rapid action is required. ■ Acute alcohol withdrawal (as an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis). ■ As an adjunct in (1) endoscopic procedures; (2) skeletal muscle spasms associated with local pathology, cerebral palsy, athetosis, stiff-man syndrome, and tetanus; and (3) status epilepticus and severe recurrent convulsive seizures. ■ As a premedication in patients undergoing surgical procedures (IM preferred) and cardioversion.
Known hypersensitivity, acute narrow-angle glaucoma, and open-angle glaucoma unless receiving appropriate therapy.
Concomitant use of benzodiazepines and opioids (e.g., morphine, hydromorphone [Dilaudid], fentanyl) may result in profound sedation, respiratory depression, coma, and death; see Drug/Lab Interactions.■ Not recommended for treatment of petit mal or petit mal variant seizures; may precipitate tonic status epilepticus. ■ Patients may experience a return to seizure activity after initial control; re-administration of diazepam may be needed. Once seizures are controlled, consideration should be given to the administration of agents useful in longer-term control of seizures. ■ Avoid use in patients in shock, coma, or in acute alcoholic intoxication with depression of vital signs. ■ Use caution in the elderly, those who are very ill, and those with limited pulmonary reserve (e.g., chronic lung disease) or unstable cardiac status; may be at increased risk of apnea and/or cardiac arrest. ■ Withdrawal symptoms will occur after extended use. Gradual tapering of dose may be indicated. ■ Use caution in patients with impaired renal or hepatic function. ■ Intended for short-term use only. ■ Available PO and as a rectal gel.
See Dilution. ■ To reduce the incidence of venous thrombosis, phlebitis, or local irritation, avoid smaller veins (such as the dorsum of the hand or wrist) and administer injection slowly. Extravasation or arterial administration hazardous. ■ Oxygen, respiratory assistance, and flumazenil must always be available. ■ Monitor vital signs. ■ Monitor patients for respiratory depression and sedation, especially when used concomitantly with opioids and other CNS depressants; see Drug/Lab Interactions.■ EEG monitoring may be useful for monitoring seizure activity. ■ Periodic CBC and liver function tests may be indicated with long-term use.
May produce drowsiness or dizziness. Request assistance with ambulation and use caution performing tasks that require alertness. Do not drive or operate hazardous machinery until all effects have subsided. ■ Avoid use of alcohol or other CNS depressants (e.g., antihistamines, barbiturates). ■ May be habit-forming with long-term use or high-dose therapy. ■ Has amnesic potential; may impair memory. ■ Consider birth control options.
Studies suggest an increased risk of birth deformities with use during pregnancy, especially in the first trimester. ■ Not recommended during pregnancy, childbirth, or while breast-feeding. ■ Efficacy and safety have not been established in neonates (30 days or less of age). ■ May contain benzyl alcohol, which has been associated with fatal gasping syndrome in premature infants.
See Dose Adjustments. Start with a small dose and increase gradually based on response. ■ More sensitive to therapeutic and adverse effects (e.g., ataxia, dizziness, oversedation). ■ IV injection may be more likely to cause apnea, bradycardia, hypotension, and cardiac arrest. ■ See Precautions and Drug/Lab Interactions.
Concomitant use ofbenzodiazepines and opioids(e.g., morphine, hydromorphone, fentanyl) may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required, and monitor for S/S of respiratory depression and sedation.■ When given concomitantly with a narcotic, the dosage of the narcotic should be reduced by at least one-third and administered in small increments. ■ Concurrent use with other CNS depressants (e.g., alcohol, antihistamines, barbiturates, MAO inhibitors, phenothiazines, tricyclic antidepressants) may result in additive effects. Reduced dose may be indicated. Monitor for S/S of respiratory depression and sedation. ■ May increase serum concentrations of digoxin and phenytoin; monitor serum levels. ■ Ritonavir may increase risk of prolonged sedation and respiratory depression. ■ Concurrent use with beta-blockers, cimetidine, disulfiram, fluoxetine, isoniazid, itraconazole, ketoconazole, omeprazole, and probenecid may inhibit hepatic metabolism, resulting in increased plasma concentrations of benzodiazepines. ■ May decrease effectiveness of levodopa.■ Hypotensive effects of benzodiazepines may be increased by any agent that induces hypotension (e.g., antihypertensives, CNS depressants, diuretics, lidocaine, paclitaxel). ■ Use with rifampin increases clearance and reduces effects of diazepam. ■ Theophyllines (e.g., aminophylline) antagonize sedative effects of benzodiazepines. ■ Smoking increases metabolism and clearance of diazepam, decreasing plasma levels and sedative effects. ■ Clozapine has caused respiratory distress or cardiac arrest in a few patients; use concurrently with extreme caution. ■ Grapefruit juice may affect certain enzymes of the P450 enzyme system and should be avoided.
Ataxia, drowsiness, fatigue, phlebitis, and venous thrombosis are the most commonly reported adverse reactions. Other reported reactions include apnea, blurred vision, bradycardia, cardiovascular collapse, changes in salivation, confusion, constipation, coughing, depressed respiration, depression, diplopia, dysarthria, dyspnea, headache, hiccups, hyperexcited states, hyperventilation, hypoactivity, hypotension, incontinence, jaundice, laryngospasm, nausea, neutropenia, nystagmus, rash, slurred speech, syncope, tremor, urinary retention, urticaria, and vertigo.
Diminished reflexes, coma, confusion, and somnolence.
Notify the physician of all side effects. Reduction of dosage may be required. Discontinue the drug for major side effects or paradoxical reactions, including hyperexcitability, hallucinations, and acute rage. Flumazenil will reverse all sedative effects of benzodiazepines. A patent airway, artificial ventilation, oxygen therapy, and other symptomatic treatment must be instituted promptly. Monitor respiration, heart rate, and BP. May cause emesis; observe closely. Treat hypersensitivity reaction, or resuscitate as necessary.