III. Contraindications

  1. Acute Narrow Angle Glaucoma
  2. Untreated Open Angle Glaucoma
  3. Children under age 6 years

IV. Pharmacokinetics

  1. Half Life: 20-90 hours
  2. High lipid solubility
  3. Rapid onset of action (1-3 minutes)

V. Precautions

  1. Avoid when requiring optimal mental status
    1. Driving
    2. Operating machinery
  2. Use caution if risk of cardiopulmonary depression
    1. Elderly
    2. Very ill patients
    3. Limited pulmonary reserve (e.g. COPD)
  3. Do not use with other cardiopulmonary depressants
    1. Alcohol
    2. Barbiturates
  4. Intravenous Injection
    1. Inject intravenously slowly (1 ml per minute)
    2. Reduce dose to 70% when administering with Narcotic

VI. Adverse Reactions

  1. Common General affects
    1. Drowsiness
    2. Fatigue
    3. Ataxia
    4. Benzodiazepine Dependence with withdrawal symptoms
  2. Local injection side affects (inject slowly)
    1. Venous thrombosis
    2. Phlebitis
  3. Less common, but serious reactions
    1. Hypotension
    2. Respiratory depression

VII. Dosing

  1. Anxiety Disorder
    1. Dose: 2 to 10 mg PO bid to qid
    2. Maximum Daily Dose: 40 mg
  2. Acute Alcohol Withdrawal
    1. First day: 10 mg PO tid to qid
    2. Next days: 5 mg PO tid to qid
  3. Musculoskeletal spasm
    1. Dose: 2 to 10 mg PO tid to qid
  4. Seizure Disorder
    1. See Status Epilepticus
    2. IV or IM: 0.1 to 0.3 mg/kg IV up to 8-10 mg/dose maximum (may repeat once in 5 minutes)
    3. Rectal: 0.5 mg/kg per Rectum up to maximum of 20 mg
      1. Instill via lubricated Feeding Tube inserted 4-5 cm into the Rectum OR
      2. Via tuberculin syringe (without needle) intra-rectally
      3. Hold buttocks closed after instilling medication
    4. Diazepam is as effective as Lorazepam in Status Epilepticus
      1. Chamberlain (2014) JAMA 311(16): 1652-60
    5. Diazepam IM dosing is as effective as IV dosing
      1. Silbergleit (2012) N Engl J Med 366:591-600

    6. Antiepileptic activity is short (5 to 15 minutes)
      1. Must be immediately followed with longer acting anticonvulsant (e.g. Fosphenytoin) due to short duration
  5. Older patients or with comorbid condition
    1. Dose: 2 to 2.5 mg PO qd to bid

VIII. Preparations

  1. Equivalents to 10 mg Diazepam (for withdrawal protocol)
    1. Alprazolam (Xanax) 1 mg
    2. Chlordiazepoxide (Librium) 25 mg
    3. Clonazepam (Klonopin) 4 mg
    4. Flurazepam (Dalmane) 15 mg
    5. Halazepam (Paxipam) 40 mg
    6. Lorazepam (Ativan) 2 mg
    7. Oxazepam (Serax) 10 mg
    8. Temazepam (Restoril) 10 mg
  2. Equivalents to 60 mg Diazepam (for withdrawal protocol)
    1. Alprazolam (Xanax) 6 mg
    2. Chlordiazepoxide (Librium) 150 mg
    3. Clonazepam (Klonopin) 24 mg
    4. Flurazepam (Dalmane) 90 mg
    5. Halazepam (Paxipam) 240 mg
    6. Lorazepam (Ativan) 12 mg
    7. Oxazepam (Serax) 60 mg
    8. Temazepam (Restoril) 60 mg

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Cost: Medications

diazepam (on 12/21/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
DIAZEPAM 10 MG RECTAL GEL SYST Generic $247.64 each
DIAZEPAM 10 MG TABLET Generic $0.02 each
DIAZEPAM 2 MG TABLET Generic $0.02 each
DIAZEPAM 20 MG RECTAL GEL SYST Generic $244.45 each
DIAZEPAM 5 MG TABLET Generic $0.02 each
DIAZEPAM 5 MG/5 ML SOLUTION Generic $0.11 per ml
DIAZEPAM 5 MG/ML ORAL CONC Generic $0.97 per ml

Ontology: Diazepam (C0012010)

Definition (MSH) A benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant, and amnesic properties and a long duration of action. Its actions are mediated by enhancement of GAMMA-AMINOBUTYRIC ACID activity.
Definition (CHV) antianxiety drug
Definition (NCI) A benzodiazepine derivative with anti-anxiety, sedative, hypnotic and anticonvulsant properties. Diazepam potentiates the inhibitory activities of gamma-aminobutyric acid (GABA) by binding to the GABA receptor, located in the limbic system and the hypothalamus. This increases the frequency of chloride channel opening, allowing the flow of chloride ions into the neuron and ultimately leading to membrane hyperpolarization and a decrease in neuronal excitability.
Definition (NCI_NCI-GLOSS) A drug used to treat mild to moderate anxiety and tension and to relax muscles. It is a type of benzodiazepine.
Definition (CSP) benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant, and amnesic properties and a long duration of action; its actions are mediated by enhancement of amma-aminobutyric acid activity; it is used in the treatment of severe anxiety disorders, as a hypnotic in the short-term management of insomnia, as a sedative and premedicant, as an anticonvulsant, and in the management of alcohol withdrawal syndrome.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D003975
SnomedCT 321193007, 334003005, 330105005, 323057003, 387264003, 48546005
LNC LP16108-0, MTHU003363
English Diazepam, 7-Chloro-1,3-dihydro-1-methyl-5-phenyl-2H-1,4-benzodiazepin-2-one, 2H-1,4-Benzodiazepin-2-one, 7-chloro-1,3-dihydro-1-methyl-5-phenyl-, Diazepam [anxiolytic], Diazepam [skel musc relax], diazepam, Diazepam [anaesthesia], Diazepam [anesthesia], Diazepam [epilepsy use], Diazepam [skeletal muscle relaxant], DIAZEPAM, diazepam (medication), diazepam as anxiolytic (medication), diazepam as anxiolytic, Diazepam [Chemical/Ingredient], Diazepam [skeletal muscle relaxant] (product), Diazepam [anxiolytic] (product), Diazepam [epilepsy use] (product), Diazepam [anesthesia] (product), Diazepam product, Diazepam (product), Diazepam (substance), Diazepam [anesthesia] (substance), Diazepam [anxiolytic] (substance), Diazepam [epilepsy use] (substance), Diazepam [skeletal muscle relaxant] (substance)
Swedish Diazepam
Czech diazepam
Finnish Diatsepaami
Japanese ジアゼパム
Spanish diazepam (producto), diacepam, diacepam (producto), diazepam [miorrelajante], diazapam [indicado para la epilepsia] (producto), diazepam [ansiolítico] (producto), diazepam [anestésico], diazepam [miorrelajante] (producto), diazapam [indicado para la epilepsia], diazepam [ansiolítico], diazepam [anestésico] (producto), Diacepam, Valium, diacepam (sustancia), diazepam (sustancia), diazepam, Diazepam
Italian 7-Cloro-1,3-diidro-1-metil-5-fenil-2H-1,4-benzodiazepina-2-one, Diazepam
Polish Relanium, Diazepam, Walium
Portuguese Valium, Diazepam
French Diazépam, Valium
German Diazepam

Ontology: Valium (C0699187)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D003975
English diazepam (Valium) injection, valium, Valium