Diazepam

Aka: Diazepam, Valium

1. See Also
   1. Benzodiazepine
2. Indications
   1. Insomnia
   2. Anxiety Disorder
   3. Alcohol Withdrawal
   4. Seizure Disorder (esp. Status Epilepticus)
   5. Musculoskeletal spasm
   6. Tetanus
3. Contraindications
   1. Acute Narrow Angle Glaucoma
   2. Untreated Open Angle Glaucoma
   3. Children under age 6 years
4. Pharmacokinetics
   1. Half Life: 20-90 hours
   2. High lipid solubility
   3. Rapid onset of action (1-3 minutes)
5. 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
6. 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
7. 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
8. 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