What are the contraindications for Valium (diazepam)?

Contraindications for Valium (Diazepam)

Diazepam is absolutely contraindicated in patients with known hypersensitivity to the drug, myasthenia gravis, severe respiratory insufficiency, severe hepatic insufficiency, sleep apnea syndrome, and acute narrow-angle glaucoma. 1

Absolute Contraindications

The FDA drug label specifies the following conditions where diazepam must not be used:

• Hypersensitivity to diazepam - Any known allergic reaction to the medication 1
• Myasthenia gravis - Benzodiazepines can worsen muscle weakness in this autoimmune neuromuscular disorder 1
• Severe respiratory insufficiency - Risk of respiratory depression and potential respiratory failure 1
• Severe hepatic insufficiency - Impaired metabolism can lead to drug accumulation and toxicity 1
• Sleep apnea syndrome - Benzodiazepines suppress respiratory drive and can worsen apneic episodes 1
• Acute narrow-angle glaucoma - Sympathomimetic effects may increase intraocular pressure, though it may be used cautiously in open-angle glaucoma with appropriate therapy 1
• Pediatric patients under 6 months of age - Insufficient clinical experience in this population 1

Relative Contraindications and High-Risk Situations

Concomitant Use with Other CNS Depressants

• Combination with high-dose antipsychotics (particularly olanzapine) in elderly patients - Fatalities have been documented due to oversedation and respiratory depression, representing a black-box level concern 2
• Concurrent opioid use - Exponentially increases risk of respiratory depression and death 2
• Alcohol use - Additive CNS depression with potentially fatal consequences 2

Specific Vulnerable Populations

Elderly patients require extreme caution:

• Start at dramatically reduced doses (0.25-0.5 mg for benzodiazepines) to minimize adverse outcomes 2
• Significantly increased risk of falls, syncope, orthostatic hypotension, and paradoxical worsening of delirium 2
• Avoid combination therapy with antipsychotics unless absolutely unavoidable, and attempt monotherapy first 2
• Never use in elderly patients with COPD, severe pulmonary insufficiency, or sleep apnea unless the patient is imminently dying 2

Psychiatric Contraindications

• Active psychosis or schizophrenia - While one older study suggested high-dose diazepam might help neuroleptic-resistant schizophrenia 3, benzodiazepines are generally contraindicated as they can worsen psychotic symptoms 4
• History of substance abuse - Diazepam has significant addiction potential due to rapid brain penetration and reinforcing properties 5

Clinical Pitfalls to Avoid

• Do not use standard adult doses in elderly patients - This significantly increases mortality risk 2
• Avoid intramuscular administration - Diazepam's lipophilicity results in slow, erratic absorption; use lorazepam or midazolam instead if IM route is necessary 6
• Do not combine with MAO inhibitors - While this applies to stimulants rather than benzodiazepines 4, always verify drug interactions before prescribing
• Monitor for paradoxical reactions - Particularly in elderly patients where agitation may worsen rather than improve 2

Important Monitoring Considerations

When diazepam must be used despite relative contraindications:

• Use the lowest effective dose with continuous monitoring 2
• Attempt to discontinue as soon as clinically appropriate 2
• Watch for respiratory depression, oversedation, falls, and cognitive impairment 2
• Be aware that withdrawal syndrome can be severe, particularly with shorter-acting benzodiazepines, though diazepam's long half-life provides some self-tapering effect 6, 5