Common Dosing of Diazepam
For alcohol withdrawal syndrome, diazepam is dosed at 5-10 mg orally/IV/IM every 6-8 hours, or 10 mg 3-4 times daily during the first 24 hours, then reduced to 5 mg 3-4 times daily as needed; for anxiety disorders, the standard dose is 2-10 mg given 2-4 times daily. 1
Alcohol Withdrawal Syndrome
Diazepam is the gold standard benzodiazepine for alcohol withdrawal due to its long-acting properties that provide superior protection against seizures and delirium tremens compared to shorter-acting agents. 2
Standard Dosing Regimens:
- Initial 24 hours: 10 mg orally 3-4 times daily 1
- Subsequent days: Reduce to 5 mg orally 3-4 times daily as symptoms improve 1
- Alternative regimen: 5-10 mg every 6-8 hours (oral, IV, or IM routes) 2
Symptom-Triggered vs. Fixed-Dose:
- Symptom-triggered regimens are preferred over fixed-dose schedules to prevent drug accumulation, particularly important given diazepam's long half-life. 2
- Use CIWA-Ar scores to guide dosing: scores >8 indicate moderate withdrawal requiring treatment, scores ≥15 indicate severe withdrawal. 2
- A loading dose approach can be effective: 20 mg orally every 2 hours until asymptomatic, with most patients responding after 3 doses (median) over 7.6 hours. 3
Duration Limitations:
Limit benzodiazepine use to 10-14 days maximum due to abuse potential, particularly high in patients with alcohol use disorder. 2
Anxiety Disorders
Standard Dosing:
- Typical range: 2-10 mg orally 2-4 times daily depending on symptom severity 1
- Maximal effective dose: 12-18 mg/day with treatment duration of 2 or more weeks 4
- Doses of 6 mg/day show no significant difference from placebo 4
- For chronic anxiety, doses of 15-40 mg/day have been used in long-term studies 5
Special Populations
Elderly and Debilitated Patients:
- Start with 2-2.5 mg once or twice daily, then increase gradually as needed and tolerated 1
- Use lower doses (0.25-0.5 mg equivalent of shorter-acting benzodiazepines) due to increased fall risk and cognitive decline 6
Hepatic Impairment:
Switch to intermediate-acting benzodiazepines (lorazepam, oxazepam) rather than diazepam in patients with liver dysfunction, as these are safer alternatives. 2 If diazepam must be used, reduce initial doses significantly. 6
Critical Safety Considerations
Withdrawal Risk:
- Patients treated continuously for <8 months have 5% withdrawal incidence; ≥8 months have 43% withdrawal incidence. 5
- Always use gradual taper when discontinuing; if withdrawal reactions develop, pause the taper or increase to previous dose level, then decrease more slowly. 1
Paradoxical Reactions:
- Approximately 10% of patients experience paradoxical agitation with benzodiazepines. 7, 6
- Monitor closely, especially in elderly patients who are at higher risk. 6
Tolerance and Dependence:
- Tolerance to anxiolytic effects does not develop during treatment periods up to 22 weeks. 5
- However, regular use leads to physical dependence, and withdrawal reactions can produce considerable distress requiring gradual dose tapering. 5
Route-Specific Considerations
Diazepam can be administered via multiple routes (oral, IV, IM), providing flexibility in acute settings where patients may be uncooperative or unable to take oral medications. 2, 1 This is a key advantage over agents like quetiapine that are oral-only. 7