Diazepam (Valium) Indications and Dosage
- agitation †
- amnesia induction
- anxiety
- benzodiazepine withdrawal †
- chloroquine overdose †
- drug-induced seizures
- ethanol withdrawal
- insomnia †
- muscle spasm
- partial seizures
- sedation induction
- seizure prophylaxis †
- status epilepticus
- tetanus
- tonic-clonic seizures
† non-FDA-approved indication
Diazepam (Valium) Indications and Dosage
For the treatment of anxiety:
Oral dosage (oral solution or regular tablets):
Adults and adolescents: 2 - 10 mg PO two to three times per day.
Elderly: 2 - 2.5 mg PO one to two times per day, increasing the dose according to response and patient tolerability. Federal OBRA guidelines for skilled facilities recommend the dosage not exceed 5 mg/day PO, unless higher doses are necessary for maintaining functional status of the resident. OBRA guidelines state that long-acting benzodiazepines (BZD) are not to be used in long-term care residents unless a trial of a short-acting BZD has failed or the longer-acting BZD is being used to wean the patient from a short-acting BZD. Continuous use of a long-acting BZD should not exceed 4 months, unless attempted gradual dose reduction has failed.
Children and infants >= 6 months: 1 - 2.5 mg PO three to four times per day. The dose may be increased as needed and tolerated. Alternatively, a dose of 0.12 - 0.8 mg/kg/day PO in divided doses every 6 - 8 hours may be used.
Oral dosage (extended-release capsules):
Adults and adolescents: 15 or 30 mg PO once daily.
Parenteral dosage:
Adults and adolescents: 2 - 10 mg IM or IV, depending on severity of anxiety. The dose may be repeated in 3 - 4 hours. For use preoperatively as an anxiolytic, 5 - 10 mg is recommended.
Children and infants >= 6 months: 0.04 - 0.3 mg/kg/dose IM or IV every 2 - 4 hours to a maximum of 0.6 mg/kg within an 8-hour period if needed.
For the treatment of acute ethanol withdrawal:
Intravenous dosage:
Adults: Until it is known how the patient will respond, a dose of 10 mg IV initially, followed by 5 - 10 mg IV every 3 - 4 hours as needed. Doses of 5 - 10 mg IV may be given every hour if required. Some patients may require massive doses of benzodiazepines during the acute phase of ethanol withdrawal. Intravenous doses of 270 mg over 45 minutes and 2335 mg over a period of 4 days have been reported.
For the treatment of benzodiazepine withdrawal † :
Oral dosage:
Adults: Because benzodiazepine withdrawal is more pronounced with shorter-acting agents, diazepam has been proposed as the benzodiazepine of choice for managing withdrawal. Diazepam-equivalent doses have been established for some other benzodiazepines. Diazepam should be tapered off in increments of 0.5 - 2 mg per week over a period of 4 - 16 weeks.
For the treatment of muscle spasm due to local pathology such as muscle or joint inflammation or trauma; athetosis; stiff-man syndrome; tetanus; or spasticity due to upper motor neuron diseases such as cerebral palsy:
Oral dosage (oral solution or regular tablets):
Adults and adolescents: 2 - 10 mg PO three to four times per day.
Elderly: 2 - 2.5 mg PO one to two times per day, increasing the dose according to response and patient tolerability.
Children and infants >= 6 months: 1 - 2.5 mg PO three to four times per day. The dose may be increased as needed and tolerated. Alternatively, a dose of 0.12 - 0.8 mg/kg/day PO in divided doses every 6 - 8 hours may be used.
Parenteral dosage:
Adults and adolescents: 5 - 10 mg IM or IV initially, repeated every 3 - 4 hours as needed. For tetanus, larger doses may be required.
Children >= 5 years: 5 - 10 mg IM or IV every 3 - 4 hours as needed.
Children and infants 1 month - 5 years: 1 - 2 mg IM or IV every 3 - 4 hours as needed.
For the treatment of status epilepticus or for treatment of drug-induced seizures:
NOTE: Many clinicians now prefer IV lorazepam over IV diazepam for the acute treatment of seizures.
Intravenous dosage:
Adults and adolescents: 5 - 10 mg IV initially, repeated at 10 - 15 minute intervals to a maximum dosage of 30 mg. The dosage may be repeated in 2 - 4 hours if needed.
Children >= 5 years: 1 mg IV every 2 - 5 minutes to a maximum of 10 mg. The dose may be repeated in 2 - 4 hours. Alternatively, 0.05 - 0.3 mg/kg IV over 3 - 5 minutes, given every 15 - 30 minutes to a maximum total dose of 10 mg.
Children and infants 1 month - 5 years: 0.2 - 0.5 mg IV every 2 - 5 minutes to a maximum dose of 5 mg. Repeat in 2 - 4 hours as needed. Alternatively, 0.05 - 0.3 mg/kg IV over 3 - 5 minutes, given every 15 - 30 minutes to a maximum total dose of 5 mg.
Neonates: 0.1 - 0.3 mg/kg IV over 3 - 5 minutes, given every 15 - 30 minutes to a maximum total dose of 2 mg. NOTE: Not recommended as a first-line agent due to sodium benzoate and benzoic acid in the injection.
For adjunctive treatment of seizures other than status epilepticus in selected, refractory patients with partial seizures or generalized tonic-clonic seizures who require intermittent use of diazepam to control bouts of increased seizure activity:
Oral dosage (oral solution or regular tablets):
Adults and adolescents: 2 - 10 mg PO two to four times per day. The manufacturer, however, notes that diazepam is not useful as sole therapy and may not be effective as adjunctive therapy for longer than 4 months.
Elderly: 2 - 2.5 mg PO one to two times per day, increasing the dose according to response and patient tolerability.
Children and infants >= 6 months: 1 - 2.5 mg PO three to four times per day. The dose may be increased as needed and tolerated.
Rectal dosage:
NOTE: It is recommended that rectal diazepam be used to treat no more than five episodes per month and no more than one episode every five days.
NOTE: The Diastat® 2.5 mg dose may also be used as a partial replacement dose for patients who expel a portion of the first dose.
Adults, adolescents, and children 12 years of age: 0.2 mg/kg PR. Doses should be rounded upward to the next available dosage strength. A second dose, if needed, may be given 4 - 12 hours after the first dose.
Elderly and debilitated patients: 0.2 mg/kg PR. Doses should be rounded downward to reduce the likelihood of ataxia or oversedation. A second dose, if needed, may be given 4 - 12 hours after the first dose.
Children 6 - 11 years: 0.3 mg/kg PR. Doses should be rounded upward to the next available dosage strength. A second dose, if needed, may be given 4 - 12 hours after the first dose.
Children 2 - 5 years: 0.5 mg/kg PR. Doses should be rounded upward to the next available dosage strength. A second dose, if needed, may be given 4 - 12 hours after the first dose.
For febrile seizure prophylaxis † :
Oral dosage:
Children and infants 6 months - 5 years: Children ranging in age from 6 months to 5 years and who had had at least one febrile seizure were randomized to receive oral diazepam 0.33 mg/kg PO every 8 hours during each episode of fever until the child was afebrile for at least 24 hours or placebo. An 82% reduction in the rate of recurrent febrile seizures was observed in the diazepam group.
For amnesia induction or for preprocedure sedation induction:
Intravenous dosage:
Adults (prior to cardioversion): 5 - 15 mg IV 5 - 10 minutes before the procedure.
Adults (prior to endoscopy): Dose may be titrated up to 20 mg IV, depending on response and patient tolerability.
Adolescents: 5 mg IV 5 - 10 minutes before the procedure. Repeat with 2.5 mg IV if needed.
Oral dosage:
Adults and adolescents: 10 mg PO 45 - 60 minutes prior to procedure.
Children (for procedures or conscious sedation): 0.2 - 0.3 mg/kg PO 45 - 60 minutes prior to procedure. Maximum dose is 10 mg PO.
For the treatment of agitation † in intensive care unit patients:
Intravenous or oral dosage:
Adults: Single doses of 2 - 5 mg IV or PO have been recommended. Repeat doses should be based on clinical response.
For the treatment of acute chloroquine overdose † in combination with epinephrine:
Intravenous dosage:
Adults: Eleven cases of acute chloroquine overdose (total ingested dose ranged 5 - 12 g) were treated with diazepam 2 mg/kg IV over 30 minutes in combination with IV epinephrine, general anesthesia with thiopental, and FiO2 40%. Diazepam was continued at a dose of 1 - 2 mg/kg/day IV for 2 - 4 additional days. Other vasopressors and/or inotropic agents were used as necessary. Ten of 11 patients were discharged alive from the hospital. The one patient who died had ingested the largest total dose (15 g) of chloroquine.
For the short-term treatment of insomnia † :
NOTE: Diazepam is not usually recommended for hypnotic use.
Oral dosage:
Adults: Initially, 2 - 5 mg PO at bedtime; dosage must be titrated and individualized according to patient response.
Elderly: Initially, 2 mg PO at bedtime; dosage must be titrated and individualized according to patient response. Due to its long half-life, diazepam is not considered a drug of choice for the treatment of insomnia in the elderly; use only when clinically necessary. Federal OBRA guidelines recommend that the dose not exceed 5 mg/day PO in residents of skilled nursing facilities. Observe for hypotension and excessive daytime sedation. Federal OBRA guidelines for skilled facilities recommend the dosage not exceed 5 mg/day PO, unless higher doses are necessary for maintaining functional status of the resident. OBRA guidelines state that long-acting benzodiazepines (BZD) are not to be used in long-term care residents unless a trial of a short-acting BZD has failed or the longer-acting BZD is being used to wean the patient from a short-acting BZD. Continuous use of a long-acting BZD should not exceed 4 months, unless attempted gradual dose reduction has failed.
Adolescents and children: Dosage not established.
Maximum Dosage Limits:
- Adults: Dosage must be individualized. Suggested maximum doses: 30 mg IV in an 8 hour period for acute anxiety; 40 mg/day PO in divided doses for anxiety, seizure prophylaxis and muscle spasm.
- Elderly: Dosage must be individualized. Suggested maximum doses: 2 - 5 mg IV as a single dose and titrated based upon indication and tolerance; 10 mg/day PO for anxiety; OBRA guidelines maximum dosage is 5 mg/day PO for anxiety/insomnia in skilled nursing facility residents.
- Adolescents and children: Dosage must be individualized. Suggested maximum dose: 0.6 mg/kg IV in 8 hour period for acute anxiety.
- Infants: Maximum dosage not established.
- Neonates: Maximum dosage not established.
Patients with hepatic impairment:
Dosage should be modified depending on clinical response and degree of hepatic impairment, but no quantitative recommendations are available.
Patients with renal impairment:
Dosage should be modified depending on clinical response and degree of renal impairment, but no quantitative recommendations are available; active and inactive diazepam metabolites are excreted by the kidney.
† non-FDA-approved indication
[ Last revised: 10/6/2005 11:52:00 AM ]
References
. Rosman NP, Colton T, Labazzo J et al. A controlled trial of diazepam administered during febrile illness to prevent recurrence of febrile seizures. N Engl J Med 1993;329:79 - 84.
. Riou B, Barriot P, Rimailho A et al. Treatment of severe chloroquine poisoning. N Engl J Med 1988;318:1 - 6.
. Tesar GE, Stern TA. Rapid tranquilization of the agitated intensive care unit patient. J Intensive Care Med 1988;3:195 - 201.
. Higgitt AC, Lader MH, Fonagy P. Clinical management of benzodiazepine dependence. Br Med J 1985;291:688 - 90.
. Woo E, Greenblatt DJ. Massive benzodiazepine requirements during acute alcohol withdrawal. Am J Psychiatry 1979;136:821 - 3.
. Bond WS, Berwish NJ, Swift B. Severe withdrawal syndrome after substitution of a short-acting benzodiazepine for a long-acting benzodiazepine. Drug Intel Clin Pharm 1985;19:742 - 4.
. Gurvich T, Cunningham JA. Appropriate Use of Psychotropic Drugs in Nursing Homes. Am Fam Physician 2000;61:1437 - 46.
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