DIAZEPAM

(dye-az'e-pam)

Diastat, Diazemuls

, Valium
Classifications: benzodiazepine anticonvulsant; anxiolytic;
Therapeutic: anticonvulsant; antianxiety
Pregnancy Category: D
Controlled Substance: Schedule IV

Availability

2 mg, 5 mg, 10 mg tablets; 1 mg/mL, 5 mg/mL, 5 mg/5 mL oral solution; 5 mg/mL injection; 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg rectal gel

Action

Long-acting benzodiazepine psychotherapeutic agent. Benzodiazepines act at the the limbic, thalamic, and hypothalamic regions of the CNS and produce CNS depression resulting in sedation, hypnosis, skeletal muscle relaxation, and anticonvulsant activity dependent on the dosage.

Therapeutic Effect

Has antianxiety, anticonvulsant, and skeletal muscle relaxation properties.

Uses

Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of anxiety symptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic procedures, as an amnesic, and treatment for restless legs. Also used to alleviate acute withdrawal symptoms of alcoholism, voiding problems in older adults, and adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff-man syndrome, tetanus.

Contraindications

Acute narrow-angle glaucoma, untreated open-angle glaucoma; during or within 14 d of MAOI therapy; pregnancy (category D), lactation. Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetric patients, infants <30 d of age. Tablet form: Infants <6 mo of age.

Cautious Use

Epilepsy, psychoses, mental depression; myasthenia gravis; impaired hepatic or renal function; neuromuscular disease; bipolar disorder, dementia, Parkinson's disease; organic brain syndrome, psychosis, suicidal ideation; drug abuse, addiction-prone individuals. Use injectable diazepam used with extreme caution in older adults, the very ill, and patients with COPD, or asthma.

Route & Dosage

Status Epilepticus
Adult: IV/IM 5–10 mg, repeat if needed at 10–15 min intervals up to 30 mg, then repeat if needed q2–4h
Child (≥5 y): IV 1 mg/kg q2–5min (max 10 mg) may repeat in 2–4 h
Child/Infant (1 mo–5 y): IV 0.2–0.5 mg slowly q2–5min up to 5 mg
Neonate: IV 0.1–0.3 mg/kg q15–30min (max total dose 2 mg)

Muscle Spasm
Adult/Adolescent/Child (≥5 y): IV 5–10 mg q3–4h prn (larger dose for tetanus)
Child/Infant (1 mo–5 y): IV 1–2 mg q3–4h prn

Anxiety
Adult/Adolescent: IV 2–10 mg, repeat if needed in 3–4 h
Child/Infant (≥6 mo): IV 0.04–0.3 mg q2–4h (max 0.6 mg/kg/8 h)

Alcohol Withdrawal
Adult: IV 10 mg then 5–10 mg in 3–4 h

Preoperative
Adult: IV 5–15 mg 5–10 min before procedure

Administration

Oral

Ensure that sustained release form is not chewed or crushed. It MUST be swallowed whole. Give other tablets crushed with fluid or mixed with food if necessary.
Supervise oral ingestion to ensure drug is swallowed.
Avoid abrupt discontinuation of diazepam. Taper doses to termination.

Intramuscular

Give deep into large muscle mass. Inject slowly. Rotate injection sites.
Do NOT give emulsion form (Dizac) as IM or SC. It is for IV use only.

Intravenous

PREPARE: Direct: Do not dilute or mix with any other drug.

ADMINISTER: Direct: Give direct IV by injecting drug slowly, taking at least 1 min for each 5 mg (1 mL) given to adults and taking at least 3 min to inject 0.25 mg/kg body weight of children.

If injection cannot be made directly into vein, inject slowly through infusion tubing as close as possible to vein insertion.
The emulsion form is incompatible with PVC infusion sets.
Avoid small veins and take extreme care to avoid intraarterial administration or extravasation.

INCOMPATIBILITIES Solution/additive: Bleomycin, dobutamine, doxorubicin, epinephrine, fluorouracil, furosemide, glycopyrrolate, nalbuphine, sodium bicarbonate. Emulsion also incompatible with morphine. Y-site: Amphotericin B cholesteryl complex, atracurium, bivalirudin, cefepime, dexmedetomidine, diltiazem, fenoldopam, fluconazole, foscarnet, furosemide, heparin, hetastarch, lansoprazole, linezolid, meropenem, oxaliplatin, pancuronium, potassium chloride, propofol, remifentanil, tirofiban, vecuronium, vitamin B complex with C. Do not mix emulsion with any other drugs. Do not administer through polyvinyl chloride (PVC) infusion sets.

Store in tight, light-resistant containers at 15°–30° C (59°–86° F), unless otherwise specified by manufacturer. Store Dizac emulsion at 2°–8° C (36°–46° F). Do not freeze.

Adverse Effects (≥1%)

Body as a Whole: Throat and chest pain. CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia. CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. GI: Xerostomia, nausea, constipation, hepatic dysfunction. Urogenital: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site.

Interactions

Drug: Alcohol, cns depressants, anticonvulsants potentiate CNS depression; cimetidine increases diazepam plasma levels, increases toxicity; may decrease antiparkinson effects of levodopa; may increase phenytoin levels; smoking decreases sedative and antianxiety effects. Herbal: Kava, valerian may potentiate sedation.

Pharmacokinetics

Absorption: Readily from GI tract; erratic IM absorption. Onset: 30–60 min PO; 15–30 min IM; 1–5 min IV. Peak: 1–2 h PO. Duration: 15 min–1 h IV; up to 3 h PO. Distribution: Crosses blood–brain barrier and placenta; distributed into breast milk. Metabolism: In liver to active metabolites. Elimination: Primarily in urine. Half-Life: 20–50 h.

Nursing Implications

Assessment & Drug Effects

Monitor for adverse reactions. Most are dose related. Physician will rely on accurate observation and reports of patient response to the drug to determine lowest effective maintenance dose.
Monitor for therapeutic effectiveness. Maximum effect may require 1–2 wk; patient tolerance to therapeutic effects may develop after 4 wk of treatment.
Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states accompanied by depression.
Observe patient closely and monitor vital signs when diazepam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur.
Lab tests: Periodic CBC and liver function tests during prolonged therapy.
Supervise ambulation. Adverse reactions such as drowsiness and ataxia are more likely to occur in older adults and debilitated or those receiving larger doses. Dosage adjustment may be necessary.
Monitor I&O ratio, including urinary and bowel elimination.
Note: Smoking increases metabolism of diazepam; lowering clinical effectiveness. Heavy smokers may need a higher dose than the nonsmoker.
Note: Psychic and physical dependence may occur in patients on long-term high dosage therapy, in those with histories of alcohol or drug addiction, or in those who self-medicate.

Patient & Family Education

Avoid alcohol and other CNS depressants during therapy unless otherwise advised by physician. Concomitant use of these agents can cause severe drowsiness, respiratory depression, and apnea.
Do not drive or engage in other potentially hazardous activities or those requiring mental precision until reaction to drug is known.
Tell physician if you become or intend to become pregnant during therapy; drug may need to be discontinued.
Take drug as prescribed; do not change dose or dose intervals.
Check with physician before taking any OTC drugs.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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