Is intravenous (IV) diazepam suitable for end of life care?

IV Diazepam in End of Life Care

IV diazepam is suitable for end of life care as a second-line benzodiazepine option when managing anxiety, agitation, and seizures, though midazolam is generally preferred due to its more favorable pharmacokinetic profile. 1

Indications for IV Diazepam in End of Life Care

Diazepam can be used in palliative care for:

• Anxiety and agitation: When patients are unable to swallow oral medications
• Seizure management: Particularly for status epilepticus or recurrent seizures
• Palliative sedation: For refractory symptoms when other approaches have failed

Medication Selection Algorithm

First-line benzodiazepine:

• Midazolam: Preferred due to:
  • Rapid onset of action
  • Short duration (allows better dose titration)
  • Water solubility (compatible with subcutaneous or IV administration)
  • Can be co-administered with morphine or haloperidol 1
  • Starting dose: 0.5-1 mg/h IV, with 1-5 mg as needed
  • Usual effective dose: 1-20 mg/h

When to consider diazepam instead:

• When midazolam is unavailable
• When longer duration of action is desired
• For seizure management when IV access is available 1

Dosing Guidelines for IV Diazepam

• Initial dose: 2-5 mg IV for moderate anxiety; 5-10 mg IV for severe anxiety 2
• Administration: Inject slowly, taking at least one minute for each 5 mg (1 mL) given 2
• Repeat dosing: Can repeat in 3-4 hours if necessary 2
• Elderly/debilitated patients: Lower doses (2-5 mg) and slow increase in dosage 2

Important Precautions

• Respiratory monitoring is essential: Facilities for respiratory assistance should be readily available 2
• Avoid small veins: Do not use small veins such as those on the dorsum of the hand or wrist 2
• Avoid intra-arterial administration or extravasation 2
• Do not mix or dilute diazepam with other solutions or drugs in syringe or infusion container 2
• Reduced dosing for elderly, debilitated patients, or when other sedatives are administered 2
• Concomitant use with opioids increases risk of profound sedation, respiratory depression, and death 2

Alternatives to Consider

For anxiety/agitation when unable to swallow:

• Midazolam: 2.5-5 mg subcutaneously every 2-4 hours as required 1
• Consider subcutaneous infusion via syringe driver if needed frequently (more than twice daily) 1

For delirium when unable to swallow:

• Levomepromazine: 12.5-25 mg subcutaneously (6.25-12.5 mg in elderly patients) 1
• Maintain with subcutaneous infusion of 50-200 mg over 24 hours 1

Practical Considerations

• Continue medications for symptom palliation used before sedation unless ineffective or causing distressing side effects 1
• Patients on pain medications (e.g., opioids) before sedation should generally continue them unless adverse effects are observed 1
• If signs of opioid overdose occur, reduce doses but do not rapidly withdraw 1
• Consider the impact on family members and provide appropriate support 1

Common Pitfalls to Avoid

• Rapid administration: Can lead to respiratory depression and hypotension
• Inadequate monitoring: Always monitor respiratory status during administration
• Drug interactions: Particularly with other CNS depressants including opioids
• Paradoxical reactions: Can occur, especially in elderly patients
• Abrupt discontinuation: Can lead to withdrawal symptoms

While IV diazepam is suitable for end of life care, midazolam is generally considered the benzodiazepine of choice in palliative care settings due to its more favorable pharmacokinetic profile and flexibility in administration routes.