Benzodiazepines Available in India
In India, several benzodiazepines are available for clinical use including diazepam, lorazepam, clonazepam, alprazolam, midazolam, and temazepam, which are prescribed for various indications including anxiety disorders, insomnia, seizures, alcohol withdrawal, and acute agitation.
Commonly Available Benzodiazepines in India
Short to Intermediate-Acting Benzodiazepines
- Alprazolam: Available in tablet form (0.25mg, 0.5mg, 1mg)
- Lorazepam: Available in tablet and injectable forms (1mg, 2mg)
- Midazolam: Available primarily in injectable form for procedural sedation and status epilepticus
Intermediate-Acting Benzodiazepines
- Temazepam: Available in capsule form (7.5mg, 15mg, 22.5mg, 30mg) 1
- Oxazepam: Less commonly available
Long-Acting Benzodiazepines
- Diazepam: Available in tablet, injectable, and rectal forms (2mg, 5mg, 10mg)
- Clonazepam: Available in tablet form (0.5mg, 1mg, 2mg) 2
- Chlordiazepoxide: Available primarily for alcohol withdrawal syndrome
Clinical Indications and Dosing
Anxiety Disorders
- Diazepam: 5-10mg PO/IV/IM every 6-8 hours 3
- Alprazolam: Used for panic disorder and generalized anxiety
- Clonazepam: Used for panic disorder and social anxiety
Insomnia
- Temazepam: 15-30mg at bedtime (7.5mg in elderly or debilitated patients) 3
- Diazepam: Can be used for intermittent dosing
Seizure Management
- Lorazepam: 1mg IV/SC (up to 2mg maximum) for acute seizures 3
- Diazepam: For rectal administration when IV access not available 3
- Clonazepam: For maintenance therapy in certain seizure disorders
Alcohol Withdrawal Syndrome
- Chlordiazepoxide: 25-100mg PO every 4-6 hours 3
- Diazepam: 5-10mg PO/IV/IM every 6-8 hours 3
- Lorazepam: 1-4mg PO/IV/IM every 4-8 hours (preferred in patients with liver failure) 3
Acute Agitation/Delirium
- Lorazepam: 0.25-0.5mg SC/IV every hour as needed (in combination with antipsychotics for delirious patients with severe agitation) 3
- Midazolam: 2.5mg SC/IV every hour as needed (up to 5mg maximum) 3
Important Considerations
Safety Concerns
- Benzodiazepines can cause respiratory depression, especially when combined with other CNS depressants
- Risk of falls is increased, particularly in elderly patients 3, 4
- Paradoxical reactions (increased agitation, anxiety) can occur 3
- Cognitive impairment and delirium risk, especially in older adults 4
Dependence and Withdrawal
- Physical dependence can develop even with short-term use
- Gradual tapering (approximately 25% every 1-2 weeks) is recommended when discontinuing 4
- Withdrawal symptoms may include rebound insomnia, anxiety, irritability, tremors, and sweating 4
Special Populations
- Elderly: Use lower doses (typically half the adult dose) 3, 4
- Liver Disease: Prefer lorazepam over diazepam or chlordiazepoxide 3
- Respiratory Conditions: Use with caution in patients with COPD or sleep apnea 3
Prescribing Pitfalls to Avoid
- Avoid long-term prescribing when possible (ideally limit to 2-4 weeks) 5
- Avoid concurrent use with opioids due to risk of fatal overdose 4
- Avoid abrupt discontinuation after prolonged use
- Benzodiazepines should not be first-line treatment for chronic insomnia or anxiety disorders where other evidence-based treatments exist 6
For patients requiring long-term anxiety management, consider non-benzodiazepine alternatives such as SSRIs, SNRIs, or buspirone, which do not carry the same risks of dependence and tolerance 4.