What is the recommended dose of diazepam (Diazepam) for treating delirium tremens?

Diazepam Dosing for Delirium Tremens

For delirium tremens, administer diazepam 10 mg IV initially, then 5 mg IV every 5 minutes until the patient is calm but awake, with facilities for respiratory support immediately available. 1

Initial Loading Protocol

• Start with 10 mg IV diazepam, followed by 5 mg IV every 5 minutes until adequate sedation is achieved (calm but awake state) 1, 2
• Administer slowly—take at least one minute for each 5 mg (1 mL) given to minimize adverse effects 1
• Maximum initial dose can reach 30 mg within the first 10-15 minutes if necessary 1
• This symptom-triggered approach achieves control in approximately half the time compared to fixed-dose regimens 2

Maintenance Dosing

• After initial control, give 5-10 mg IV or IM every 3-4 hours as needed to maintain calm state 1
• If symptoms recur after 2-4 hours, repeat the loading protocol, recognizing that active metabolites may persist 1
• Some patients with severe DT may require extraordinarily high cumulative doses (260-480 mg/day or more) when standard doses fail 3, 4

Critical Monitoring Requirements

• Respiratory assistance must be readily available before initiating IV diazepam 1
• Monitor oxygen saturation and respiratory effort continuously, as rapid IV administration or combination with other sedatives increases apnea risk 5
• Assess for hypotension, particularly with rapid administration 5
• Use small veins (dorsum of hand/wrist) should be avoided; extreme care needed to prevent intra-arterial administration or extravasation 1

Special Considerations for Complicated Cases

• Patients with concurrent medical conditions (pneumonia, pancreatitis, alcoholic hepatitis) require approximately twice the diazepam dose for initial control compared to uncomplicated DT 2
• Liver disease complicates treatment choice and influences outcomes, though diazepam remains preferred 6
• In benzodiazepine-refractory cases, consider phenobarbital, propofol, or dexmedetomidine as adjuncts 6

Route Selection

• IV route is strongly preferred for active DT due to faster onset and more predictable absorption 1, 7
• IM administration (5-10 mg) may be used if IV access is impossible, though this is suboptimal for acute management 1
• Diazepam's rapid onset when given IV allows evaluation of maximal effect before the next dose, preventing oversedation 7

Common Pitfalls to Avoid

• Do not underdose out of fear of side effects—mortality from untreated DT exceeds 15%, and aggressive dosing is necessary 7, 4
• Do not mix or dilute diazepam with other solutions in the syringe or infusion container 1
• Do not give up on prolonged cases requiring extended high-dose therapy; successful outcomes are achievable with persistence 4
• Avoid using small peripheral veins which increase risk of complications 1

Why Diazepam Over Other Benzodiazepines

• Diazepam has the fastest onset of action when given IV compared to other benzodiazepines 6
• Its long half-life and active metabolites provide sustained effect, reducing breakthrough symptoms 6
• Cost-effectiveness and relative safety profile make it preferable for extended high-dose therapy compared to alternatives like midazolam 4
• Lorazepam is an alternative but has slower elimination and contains propylene glycol which can cause toxicity 8