Diazepam (Valium) Contraindications / Precautions
- abrupt discontinuation
- benzodiazepine hypersensitivity
- closed-angle glaucoma
- coma
- ethanol intoxication
- shock
- asthma
- benzodiazepine dependence
- bipolar disorder
- breast-feeding
- children
- chronic obstructive pulmonary disease (COPD)
- CNS depression
- dementia
- depression
- driving or operating machinery
- elderly
- extravasation
- hepatic disease
- infants
- intraarterial administration
- mania
- myasthenia gravis
- neonates
- neuromuscular disease
- obstetric delivery
- Parkinson’s disease
- pregnancy
- psychosis
- pulmonary disease
- renal failure
- renal impairment
- respiratory depression
- seizure disorder
- seizures
- sleep apnea
- status epilepticus
- substance abuse
- suicidal ideation
- tobacco smoking
Diazepam (Valium) Contraindications / Precautions
Diazepam is contraindicated in any patient with a known or suspected hypersensitivity to diazepam, other benzodiazepine hypersensitivity, or with sensitivity to any component of the formulation.
Intravenous diazepam should be injected slowly to reduce the possibility of local reactions (diazepam-administration/">see Administration); avoid intraarterial administration or extravasation. Do not dilute diazepam injection with other solutions or drugs. If direct IV access is not feasible, inject slowly via infusion tubing as close as possible to the vein insertion.
Although diazepam is occasionally beneficial for patients with major depression , the drug should be administered cautiously to patients with suicidal ideation. Large quantities of benzodiazepines should not be prescribed for patients with known suicidal ideation or a history of suicide attempt. Benzodiazepines should be used cautiously in patients with bipolar disorder because mania and hypomania have been reported in conjunction with the use of benzodiazepines in depressive disorders. The manufacturer states that diazepam has no use in psychosis and should not be used in lieu of appropriate therapy.
Diazepam can cause physical and psychological dependence, and should be used with extreme caution in patients with known, suspected or a history of substance abuse. Generally, benzodiazepines should be prescribed for short periods (2 - 4 weeks) with continued reevaluation of the need for treatment. Tolerance (or tachyphylaxis) may develop to the sedative effects of benzodiazepines. Patients should be questioned about the need for escalating doses, and the clinician may need to intervene to prevent further tolerance or increased risk for addiction. Abrupt discontinuation of diazepam after prolonged use should be avoided. Abrupt discontinuation of benzodiazepine therapy has been reported to cause withdrawal symptoms, especially following high dose or prolonged therapy (diazepam-adverse-reactions/">see Adverse Effects). However, benzodiazepine dependence can occur following administration of therapeutic doses for as few as 1 - 2 weeks, and withdrawal symptoms may be seen following the discontinuation of therapy. Patients with a history of a epilepsy or who are taking other drugs that lower the seizure threshold (i.e., TCAs, phenothiazines) should not be withdrawn abruptly from benzodiazepines due to the risk of precipitating a seizure. Benzodiazepines should be withdrawn slowly, using a gradual dosage-tapering schedule. During withdrawal, the greatest risk of seizure appears to be during the first 24 to 72 hours.
The use of diazepam in controlling seizure activity is relatively short-lived, and clinicians should be prepared to readminister IV diazepam if needed. Tonic status epilepticus has been precipitated in patients treated with IV diazepam for petit mal status or petit mal variant status. Most clinicians now prefer the use of IV lorazepam over IV diazepam for treatment of acute seizure activity. A longer acting anticonvulsant should be selected for maintenance treatment of seizure activity. When oral diazepam is used as an adjunct for a seizure disorder, there is the possibility of worsened seizures requiring higher dosages of standard anticonvulsant medications. Clinicians should ensure that the caregivers of patients with refractory seizures can adequately administer diazepam rectal gel, if this route and dosage form are to be used. Additionally, the caregiver should be able to identify the correct seizure clusters for which the gel is to be used, adequately monitor the patient after administration and know when to refer for immediate medical attention. Prescribers should regularly discuss the caregiver administration instructions (found in the package insert) with the caregiver and patient. Diazepam rectal gel is not recommended for chronic, daily use.
Diazepam and other benzodiazepines should be administered cautiously in patients with CNS depression. Ambulatory patients receiving diazepam should be warned of the hazards of driving or operating machinery, and should avoid engaging in these activities until the full effect of the drug has dissipated. There is a potential for synergistic CNS-depressant effects if benzodiazepines are administered concomitantly with alcohol, barbiturates, or other CNS depressants. If opiate agonists are used concomitantly, the dose of the opiate should be reduced by at least one-third. Except as indicated for acute alcohol withdrawal, diazepam should not be administered parenterally to patients with acute ethanol intoxication, shock, or coma because the drug can worsen CNS depression. Additionally, due to the potential for prolonged CNS depression with diazepam, parenteral diazepam is not recommended for use in neonates under one month of age and oral and rectal diazepam should not be used in infants < 6 months old. Further, the response of children to benzodiazepine therapy can be unpredictable. In general the pediatric population is more sensitive to the effects of the benzodiazepines. Initially, children should receive the lowest dose of diazepam, with increases made according to response. When using parenteral diazepam, age and size appropriate resuscitative equipment and trained personnel should be readily available.
Diazepam is contraindicated in patients with closed-angle glaucoma. The mechanistic rational for this contraindication has been questioned, as benzodiazepines do not have antimuscarinic activity and do not raise intraocular pressure. Benzodiazepines may be used in patients with open-angle glaucoma who are receiving appropriate therapy.
Diazepam should be used with extreme caution in patients with respiratory depression, pulmonary disease such as severe chronic obstructive pulmonary disease (COPD), asthma, pneumonia, or sleep apnea because the drug can exacerbate ventilatory failure.
Diazepam is classified in FDA pregnancy risk category D. Diazepam undergoes placental transfer. In general, the use of benzodiazepines is not life-saving and thus should be avoided in pregnancy whenever possible. An increased risk of congenital malformations is associated with benzodiazepine use in the first trimester. Diazepam is associated with teratogenic effects in animal models. Diazepam injection should not be given to a pregnant women except in serious or life-threatening situations (e.g., status epilepticus). Diazepam is not recommended for use in obstetrical procedures, labor, or obstetric delivery, including cesarean section. Neonatal flaccidity has been reported in an infant whose mother was using benzodiazepines during pregnancy.
Diazepam is distributed into breast milk and can cause sedation, feeding difficulties, and weight loss in the nursing infant. The use of diazepam during breast-feeding is generally not recommended.
Diazepam should be administered cautiously to patients with severe hepatic disease because its elimination half-life can be prolonged, possibly resulting in toxicity. Diazepam is metabolized to an active metabolite, and patients with hepatic disease are more likely to experience adverse CNS reactions and should receive reduced initial dosages.
Patients with renal impairment (including renal failure) should be carefully monitored during prolonged treatment with diazepam to avoid the adverse reactions that may occur from drug accumulation. The active metabolites of diazepam are excreted by the kidney.
Diazepam should be used with caution in patients with a neuromuscular disease, such as muscular dystrophy, myotonia, or myasthenia gravis as these conditions can be exacerbated. Patients with late stage Parkinson’s disease may experience worsening of their psychosis or impaired cognition with administration of benzodiazepines. Benzodiazepines may also cause incoordination or paradoxical reactions that may worsen symptoms of Parkinson’s disease. Use cautiously in patients with organic brain syndromes (e.g., dementia) or other types of psychosis.
The clearance and/or elimination of many drugs are reduced in the elderly or debilitated patient. Delayed elimination can either intensify or prolong the actions of adverse reactions of the drug. Benzodiazepines have been associated with falls in the elderly. The impairment of cognitive and motor function may be more marked in this patient group and lower initial dosage is recommended together with close monitoring (diazepam-valium-indications-and-dosage/">see Dosage). Use caution when administering IV diazepam to the elderly due to the risk of apnea and/or cardiac arrest. Federal OBRA regulations recommend maximum dosage limits for anxiolytic and hypnotic use in the nursing home resident (diazepam-valium-indications-and-dosage/">see dosage); the use of long-acting benzodiazepines is discouraged.
Tobacco smoking does not affect the metabolism of the parent drug diazepam, but does accelerate the metabolism of its major active metabolite, N-desmethyldiazepam, by up to 3-fold. Conversely, because the effect on hepatic microsomal enzymes is not related to the nicotine component of tobacco, sudden smoking cessation may result in a reduced clearance of this diazepam metabolite, despite the initiation of nicotine replacement. No specific dosage adjustment recommendations are available, but monitor patients for the desired clinical effects when changes in tobacco smoking status occur.
[ Last revised: 10/6/2005 11:52:00 AM ]
References
. Carter K, Faberowski LK, Sherwood MB, et al. A randomized trial of the effect of midazolam on intraocular pressure. J Glaucoma 1999;8:204 - 7.
. Gurvich T, Cunningham JA. Appropriate Use of Psychotropic Drugs in Nursing Homes. Am Fam Physician 2000;61:1437 - 46.
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