What is the typical dosage for benzodiazepines (BZD)?

Benzodiazepine Dosing

I need to clarify that "benzotate" appears to be a misspelling—benzonatate is a cough suppressant unrelated to benzodiazepines (BZDs), which are anxiolytic/sedative medications. If you're asking about benzodiazepine dosing, I'll provide comprehensive guidance below. If you meant benzonatate specifically, please clarify.

Benzodiazepine Dosing by Indication

Anxiety Management

For anxiety disorders, diazepam 2-10 mg given 2-4 times daily is the standard approach, with dosing individualized based on symptom severity. 1

• Start with lower doses (2-5 mg) and titrate upward as needed 1
• Prescriptions should be limited to single doses, very short courses (1-7 days), or short courses (2-4 weeks) maximum 2
• Lorazepam and oxazepam are alternatives with shorter half-lives, which may be preferable to minimize accumulation 3

Insomnia

For sleep disorders, prescriptions should be limited to a few days, occasional/intermittent use, or courses not exceeding 2 weeks. 2

• Temazepam 15-30 mg at bedtime (7.5 mg in elderly/debilitated) 3
• Triazolam 0.25 mg at bedtime (0.125 mg in elderly; maximum 0.5 mg) 3
• Diazepam can be effective in single or intermittent dosing 2
• Short- to intermediate-acting agents are preferred over long-acting ones like flurazepam, which carries significant risk of residual daytime drowsiness 3

Acute Alcohol Withdrawal

• Diazepam 10 mg, 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 1

Skeletal Muscle Spasm

• Diazepam 2-10 mg, 3-4 times daily 1

Status Epilepticus (Pediatric)

• IV diazepam 0.1-0.3 mg/kg every 5-10 minutes (maximum 10 mg per dose) 3

Special Population Adjustments

Elderly or Debilitated Patients

Reduce initial doses by 50% or more in geriatric patients due to increased sensitivity and risk of adverse effects. 4

• Diazepam: Start with 2-2.5 mg once or twice daily 1
• Temazepam: 7.5 mg at bedtime 3
• Triazolam: 0.125 mg at bedtime (maximum 0.25 mg) 3
• Infrequent, low doses of agents with short half-lives are least problematic in this population 3

Pediatric Patients

• Diazepam 1-2.5 mg, 3-4 times daily initially; increase gradually as tolerated 1
• Not for use in children under 6 months of age 1

Critical Safety Considerations

Risk of Dependence and Tolerance

Regular benzodiazepine use can lead to tolerance, addiction, depression, and cognitive impairment, even at therapeutic doses. 3

• Physical dependence is a risk with long-term use, even at low therapeutic doses (10-20 mg diazepam equivalent daily) 5
• 80% of benzodiazepines are prescribed for 6 months or less; courses exceeding 4 weeks should be rare 2, 6
• Dose escalation is uncommon in medically supervised patients but typical in recreational users 6

Paradoxical Reactions

• Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 3
• If this occurs, discontinue the medication rather than increase the dose 7

Discontinuation Protocol

Always use a gradual taper over at least 6 weeks to minimize withdrawal reactions; abrupt discontinuation can produce severe withdrawal symptoms similar to alcohol or barbiturates. 3, 1

• If withdrawal reactions develop, pause the taper or increase to the previous dosage level 1
• Very prolonged tapering schedules (beyond several months) may be counter-productive 7
• Substituting a long-acting benzodiazepine for a medium-acting one may help in difficult cases 7

Drug Interactions

Benzodiazepines have synergistic respiratory depressant effects when combined with opioids or other CNS depressants, significantly increasing risk of adverse outcomes. 4

• Avoid alcohol and other sedatives during benzodiazepine therapy 3
• When combined with opioids, there is increased incidence of apnea; be prepared to provide respiratory support 3

Patient Selection

Avoid benzodiazepines in patients with history of alcohol or drug abuse, as dependent personalities pose higher risk of addiction. 8

• Recreational benzodiazepine users are typically young men with polysubstance abuse patterns 6
• Long-term therapeutic users are typically elderly women on low, stable doses 6

Monitoring Requirements

• Document indication for use and collect drug-abuse history before prescribing 6
• Monitor for signs of tolerance (dose escalation requests) 8
• Consider drug holidays to assess continued need 6
• Respiratory monitoring is essential, particularly when combined with other sedatives 3