From the Guidelines
For anxiety or agitation in palliative care, oral midazolam is typically dosed at 2.5-5 mg every 4 hours as needed, with a usual starting dose of 2.5 mg in elderly or frail patients. The dose can be titrated upward based on response and tolerability, with some patients requiring up to 10 mg per dose. Midazolam works rapidly, with onset within 15-30 minutes after oral administration, by enhancing the inhibitory effects of GABA in the central nervous system 1. When administering oral midazolam, monitor for excessive sedation, respiratory depression, and paradoxical reactions, especially in elderly patients or those with hepatic impairment. The medication can be given via oral solution (often available as 2 mg/mL) or by using the injectable form administered orally (typically 5 mg/mL). For patients unable to swallow, buccal administration is an alternative using the same dosing. Midazolam should be used cautiously alongside other CNS depressants, and doses should be reduced in patients with advanced liver disease or severe renal impairment.
Some key points to consider when using midazolam in palliative care include:
- Starting with a low dose and titrating upward as needed to minimize the risk of adverse effects
- Monitoring patients closely for signs of excessive sedation, respiratory depression, and paradoxical reactions
- Using alternative routes of administration, such as buccal or subcutaneous, if oral administration is not feasible
- Being cautious when co-administering midazolam with other CNS depressants, and reducing doses in patients with advanced liver disease or severe renal impairment 1.
It's also important to note that midazolam is a short-acting benzodiazepine, and its use should be tailored to the individual patient's needs and response to treatment 1.
From the Research
Midazolam PO Dose in Palliative Care
- The oral (PO) dose of midazolam in palliative care for anxiety or agitation is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, the studies suggest that midazolam is commonly used in palliative care for the treatment of anxiety, agitation, and other symptoms 3, 4.
- The dosage of midazolam should be carefully considered, taking into account the patient's age, liver and renal function, and other medications they are taking 2, 3.
- A combination of haloperidol and midazolam has been shown to be effective and safe for the control of agitation in palliative care 5, 6.
- The studies do not provide a specific oral dose of midazolam for palliative care, but rather emphasize the importance of careful dosing and monitoring to avoid adverse effects 2, 3, 4.
Administration and Monitoring
- Midazolam can be administered subcutaneously or orally, but the oral route is not explicitly discussed in the provided studies 2, 3, 4.
- The pharmacokinetics of midazolam depend on hepatic and renal functions, fat tissue mass, route and duration of administration, as well as potential drug-drug interactions 3.
- Patients in palliative care are at high risk of side effects due to polytherapy and multi-organ failure, and therefore require close monitoring when receiving midazolam 3.