Diazepam IV Dosing for Alcohol Withdrawal
For alcohol withdrawal syndrome, intravenous diazepam should be administered at 5-10 mg every 6-8 hours as a standard fixed-dose regimen, with dose adjustments based on severity and individual patient factors. 1
Dosing Protocol
Standard Dosing
- Initial dose: 5-10 mg IV administered slowly over 1-2 minutes 1, 2
- Frequency: Every 6-8 hours as needed 1
- Maximum daily dose: Generally not exceeding 30 mg in 24 hours for most patients 2
Severe Withdrawal/Delirium Tremens
- Initial dose: 10 mg IV 2
- Follow-up dosing: 5-10 mg IV every 3-4 hours as needed 2
- For resistant alcohol withdrawal: May require higher doses based on symptom response 3
Special Populations
- Elderly or debilitated patients: Reduce initial dose by 20-50% (2-5 mg IV) 1, 2
- Patients with hepatic dysfunction: Consider using shorter-acting benzodiazepines like lorazepam instead 1
Monitoring and Administration
Administration Technique
- Inject slowly, taking at least one minute for each 5 mg given 2
- Use larger veins, avoiding small veins on the dorsum of the hand or wrist 2
- Extreme care should be taken to avoid intra-arterial administration or extravasation 2
Monitoring Parameters
- Use CIWA-Ar score to guide treatment intensity:
- CIWA-Ar score >8: Moderate withdrawal requiring treatment
- CIWA-Ar score ≥15: Severe withdrawal requiring more aggressive treatment 1
- Monitor vital signs, respiratory status, and level of consciousness
- Symptom-triggered regimen is preferred over fixed-dose schedule to prevent drug accumulation 1
Important Clinical Considerations
Advantages of Diazepam
- Long-acting benzodiazepines like diazepam provide better protection against seizures and delirium than short-acting alternatives 1
- The long half-life of diazepam and its active metabolites provides a natural tapering effect 4
Cautions and Contraindications
- Have respiratory support readily available when administering IV diazepam 2
- Avoid use beyond 10-14 days due to potential for abuse, especially in patients with alcohol use disorder 1
- Consider lorazepam for patients with hepatic dysfunction, advanced age, or respiratory compromise 1
Treatment Pitfalls to Avoid
- Underdosing: Inadequate dosing may lead to progression to more severe withdrawal, including seizures and delirium tremens 5
- Delayed treatment: Complications of alcohol withdrawal are more likely when therapy is delayed 4
- Rapid administration: Too rapid IV administration can cause respiratory depression 2
- Overlooking thiamine: Always administer thiamine (100-300 mg/day) to prevent Wernicke encephalopathy 1
Recent evidence suggests that front-loading with higher doses of diazepam may reduce the need for physical restraints and shorten hospital length of stay in some patients 6, but this approach should be used cautiously and with close monitoring.