From the Guidelines
For adult sedation, midazolam is recommended to be administered at an initial IV dose of 1-2 mg given slowly over 1-2 minutes, with titration to effect up to a total dose of 6 mg or less, as indicated by the most recent and highest quality study 1. The dosage and administration of midazolam for sedation in adults should be individualized based on patient factors, including age, weight, comorbidities, and concomitant medications.
- Key considerations for dosing include:
- Initial dose: 1-2 mg IV for healthy adults younger than 60 years of age
- Titration: additional doses of 1 mg may be administered at 2-minute intervals until adequate sedation is achieved
- Total dose: typically not exceeding 6 mg
- Dose reduction: 20% or more for patients older than 60 or with ASA physical status 3 or above Midazolam's pharmacokinetics, including its rapid onset of action and shorter duration of effect, make it a preferred choice for procedural sedation, as noted in the study by 1.
- Important safety considerations include:
- Monitoring for respiratory depression and hypotension
- Availability of resuscitation equipment
- Potential for synergistic interaction with opioids, requiring dose reduction
- Reversal of effects with flumazenil if necessary The most recent study 1 provides the highest quality evidence for the recommended dosage and administration of midazolam for sedation in adults, and its findings should be prioritized in clinical practice.
From the FDA Drug Label
For sedation/anxiolysis/amnesia for procedures, dosage must be individualized and titrated. Midazolam should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. Healthy Adults Below the Age of 60: Titrate slowly to the desired effect, e.g., the initiation of slurred speech. Some patients may respond to as little as 1 mg. No more than 2.5 mg should be given over a period of at least 2 minutes. Patients Age 60 or Older, and Debilitated or Chronically Ill Patients: Because the danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients and those with chronic disease states or decreased pulmonary reserve, and because the peak effect may take longer in these patients, increments should be smaller and the rate of injection slower. Titrate slowly to the desired effect, e.g., the initiation of slurred speech. Some patients may respond to as little as 1 mg. No more than 1.5 mg should be given over a period of no less than 2 minutes.
The recommended dosage and administration of midazolam for sedation in adults is:
- Initial dose: 1-2.5 mg for healthy adults below 60 years, and 1 mg for patients 60 or older, or debilitated/chronically ill patients
- Titration: Slow titration over at least 2 minutes, with an additional 2 or more minutes to evaluate the sedative effect
- Maximum dose: 2.5 mg for healthy adults, and 1.5 mg for patients 60 or older, or debilitated/chronically ill patients
- Administration: Intravenous administration, with the option to dilute with 0.9% sodium chloride or 5% dextrose in water 2 2
From the Research
Recommended Dosage and Administration of Midazolam for Sedation in Adults
The recommended dosage and administration of midazolam for sedation in adults vary depending on the route of administration and the specific procedure being performed.
- Intravenous midazolam is commonly used for sedation before diagnostic and therapeutic medical procedures, with a typical dose range of 0.5-2 mg administered over 1-2 minutes 3.
- Oral midazolam is also used for sedation, with a typical dose range of 5-10 mg administered 30-60 minutes before the procedure 3.
- Intranasal midazolam is another route of administration, with a typical dose range of 0.2-0.5 mg/kg administered 10-30 minutes before the procedure 3.
Comparison with Other Sedatives
Midazolam has been compared to other sedatives, such as propofol, in terms of efficacy and safety.
- A study found that propofol was more effective and at least as safe as midazolam for procedural sedation in the emergency department 4.
- Another study found that dexmedetomidine was not inferior to midazolam and propofol in maintaining light to moderate sedation in ICU patients, and reduced the duration of mechanical ventilation compared to midazolam 5.
- A systematic review found no significant difference in the safety profile and the proportion of successful sedation between midazolam and propofol for adults in the emergency department 6.
Safety and Efficacy
Midazolam is generally considered safe and effective for sedation in adults, but can cause adverse effects such as respiratory depression, hypotension, and bradycardia.
- A study found that intravenous dexmedetomidine was generally well tolerated and not associated with respiratory depression, but was associated with hypotension and bradycardia 7.
- Another study found that midazolam resulted in a higher level of sedation than placebo, but did not reduce the risk of anxiety or discomfort/pain in comparison to placebo 3.