From the Guidelines
For a patient with generalized anxiety who is being admitted for alcohol withdrawal and has Diazepam PRN ordered, it's appropriate to administer the prescribed Diazepam as needed for anxiety or withdrawal symptoms, given its effectiveness in managing both conditions and preventing serious withdrawal complications 1. The standard approach would be to use the Diazepam as ordered, typically 5-10mg orally every 4-6 hours as needed, adjusting based on the patient's response and severity of symptoms.
Key Considerations
- Diazepam is particularly effective in this situation as it serves dual purposes - managing both the anxiety and preventing serious withdrawal complications like seizures or delirium tremens.
- The long half-life of Diazepam provides a smoother control of withdrawal symptoms compared to shorter-acting benzodiazepines.
- Monitor the patient closely for respiratory depression, especially if they still have alcohol in their system.
- Vital signs, withdrawal symptoms using a scale like CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol), and level of sedation should be regularly assessed.
- Ensure adequate hydration and electrolyte replacement, particularly thiamine supplementation to prevent Wernicke's encephalopathy. Some studies suggest that benzodiazepine-sparing protocols consisting of alpha2 agonists or anticonvulsant agents could be effective in managing AWS, but these approaches need to be evaluated in larger studies 1. As the withdrawal symptoms stabilize, the Diazepam can be tapered gradually to prevent benzodiazepine dependence while maintaining control of both withdrawal and anxiety symptoms.
Monitoring and Adjustment
- Regularly assess the patient's response to Diazepam and adjust the dosage as needed.
- Consider alternative management strategies, such as alpha2 agonists or anticonvulsant agents, if the patient does not respond to Diazepam or experiences adverse effects.
- Prioritize the patient's safety and well-being, and be prepared to adjust the treatment plan as needed to minimize the risk of complications.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Dosage should be individualized for maximum beneficial effect. Management of Anxiety Disorders and Relief of Symptoms of Anxiety Depending upon severity of symptoms—2 mg to 10 mg, 2 to 4 times daily Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed
For a patient coming in for alcohol withdrawal and has Diazepam PRN for generalized anxiety, the recommended dosage is:
- 10 mg, 3 or 4 times during the first 24 hours for symptomatic relief in acute alcohol withdrawal, which may help with generalized anxiety.
- The dosage may be reduced to 5 mg, 3 or 4 times daily as needed. 2
From the Research
Generalized Anxiety in Alcohol Withdrawal
When a patient is admitted for alcohol withdrawal and has Diazepam PRN, the following options can be considered for generalized anxiety:
- Benzodiazepines, such as lorazepam or diazepam, are commonly used to manage anxiety and alcohol withdrawal symptoms 3, 4, 5, 6, 7
- Lorazepam and diazepam have been shown to be effective in reducing anxiety and preventing delirium tremens in patients with alcohol withdrawal syndrome 5, 6, 7
- Diazepam has a shorter time to peak effect and a longer elimination half-life, which can facilitate rapid control of symptoms and a smoother withdrawal 4
- The choice between lorazepam and diazepam may depend on the patient's individual needs and the availability of the medications 6, 7
Considerations for Diazepam Use
- Diazepam should not be used when intramuscular administration is the only option, as it can result in slow absorption 4
- Diazepam can be used in patients with liver disease and elderly patients, but should be administered using a simple symptom-based approach 4
- The fear of increased risk of over-sedation with diazepam is unfounded, and it can be used safely in most patients 4
Comparison of Lorazepam and Diazepam
- Lorazepam and diazepam have been shown to be equally effective in managing severe alcohol withdrawal syndrome 6, 7
- Lorazepam may be preferred due to its lower cost, but both medications can be used interchangeably based on availability 6
- The choice between lorazepam and diazepam should be based on the patient's individual needs and the clinical judgment of the healthcare provider 6, 7