What is the recommended dose of diazepam (Valium) for acute seizure management and other indications?

Diazepam Dosing for Acute Seizure Management

For acute seizure control, administer diazepam intravenously at 0.1-0.3 mg/kg every 5-10 minutes (maximum 10 mg per dose), given slowly over 2 minutes, and immediately follow with a long-acting anticonvulsant like phenytoin to prevent seizure recurrence. 1

Intravenous Administration for Status Epilepticus

• Administer 5-10 mg IV initially in adults, repeating at 10-15 minute intervals up to a maximum total dose of 30 mg 2
• For pediatric patients over 30 days and under 5 years: 0.2-0.5 mg slowly every 2-5 minutes up to maximum 5 mg 2
• For children 5 years or older: 1 mg every 2-5 minutes up to maximum 10 mg 2
• Inject slowly over approximately 2 minutes to avoid local injection site pain and reduce risk of respiratory depression 1, 2

Critical Timing Consideration

Diazepam must be followed immediately by a long-acting anticonvulsant (phenytoin/fosphenytoin 18 mg/kg loading dose) because seizures frequently recur within 15-20 minutes due to rapid redistribution 3, 1. This is a common pitfall—diazepam alone provides only temporary seizure control.

Alternative Routes When IV Access Unavailable

Rectal Administration

• Dose: 0.5 mg/kg up to 20 mg maximum 1
• Effective alternative when IV access is not immediately available 1
• Rectal gel (Diastat) has very low incidence of respiratory depression and is safe even with overdoses up to 330% of maximum recommended dose 4

Intranasal Administration

• Adults 50-100 kg: 5-10 mg 3
• Adults >100 kg: 15-20 mg 3
• Intranasal midazolam (0.2 mg/kg) may be preferable to rectal diazepam, with faster seizure cessation time and better social acceptability 5

Other Indications and Dosing

Sedation/Anxiolysis

• IV: 0.05-0.10 mg/kg over 2-3 minutes (maximum single dose: 5 mg) 6
• Peak effect occurs at 3-5 minutes; redose every 3-5 minutes to avoid oversedation 6
• PO: 0.25-0.50 mg/kg (maximum 20 mg); children <6 years may require up to 1 mg/kg 6

Moderate Anxiety

• Adults: 2-5 mg IM or IV, repeat in 3-4 hours if necessary 2

Severe Anxiety

• Adults: 5-10 mg IM or IV, repeat in 3-4 hours if necessary 2

Endoscopic Procedures

• Titrate IV dosage to desired sedative response (slurring of speech) 2
• Generally 10 mg or less adequate, up to 20 mg IV may be given 2
• If IV unavailable: 5-10 mg IM approximately 30 minutes prior 2

Muscle Spasm

• Adults: 5-10 mg IM or IV initially, then 5-10 mg in 3-4 hours if necessary 2

Essential Safety Monitoring

Be prepared to provide respiratory support regardless of administration route—there is increased incidence of apnea when diazepam is given rapidly IV or combined with other sedative agents 6, 3, 1. This is the most critical safety consideration.

Monitoring Requirements

• Continuously monitor oxygen saturation and respiratory effort 3, 1
• Monitor blood pressure and heart rate 6
• Have ventilatory support equipment immediately available 1

Reversal Agent Caution

Flumazenil may reverse life-threatening respiratory depression but will also eliminate anticonvulsant effects and may precipitate seizures 3, 1. Use only for severe respiratory compromise, not routinely.

Comparative Efficacy Note

Lorazepam may be preferred over diazepam for status epilepticus due to longer anticonvulsant duration (89% vs 76% seizure control) and lower respiratory depression risk (RR 0.72,95% CI 0.55-0.93) 1. However, diazepam remains highly effective when lorazepam is unavailable or for out-of-hospital acute seizure management.

Minimal Effective Plasma Concentration

Research demonstrates that steady-state plasma diazepam concentrations of approximately 70 ng/mL are sufficient to elevate seizure threshold 7, which is lower than previously recognized and helps guide dosing strategies for various formulations.