What is the recommended dose of diazepam (anxiolytic) for an adult patient with anxiety?

Diazepam Dosing for Anxiety in Adults

For adult patients with anxiety, diazepam should be dosed at 2-10 mg orally, 2 to 4 times daily, depending on symptom severity. 1

Standard Dosing Regimen

The FDA-approved dosing for management of anxiety disorders and relief of anxiety symptoms is:

• 2-10 mg orally, 2 to 4 times daily based on symptom severity 1
• Start at the lower end of the range (2-5 mg) for mild to moderate anxiety 1
• Use higher doses (5-10 mg) for more severe symptoms 1

Special Population Adjustments

Elderly or Debilitated Patients

• Initial dose: 2-2.5 mg, 1 to 2 times daily 1
• Increase gradually only as needed and tolerated 1
• The elderly are especially sensitive to benzodiazepine effects and require dose reduction 2

Renal Failure Patients

• No dose adjustment required for diazepam, as it is metabolized hepatically 2
• Can be safely used in patients on dialysis 2

Duration of Treatment

Limit treatment duration to minimize dependence and withdrawal risks:

• Acute stress/episodic anxiety: Single doses or 1-7 days 3
• Short-term use: 2-4 weeks maximum 3
• Courses ideally should not exceed 4 weeks to prevent tolerance and dependence 3
• Withdrawal risk is only 5% with treatment <8 months, but increases to 43% with treatment ≥8 months 4

Clinical Context and Alternatives

While the provided guidelines primarily recommend lorazepam (0.5-1 mg orally four times daily, maximum 4 mg/24 hours) for acute anxiety management in specific contexts like COVID-19 symptom management 2, diazepam remains a first-line anxiolytic with several advantages:

• Diazepam is usually the drug of choice for anxiety disorders given its efficacy and flexible dosing 3
• Effective in single doses or intermittent use for episodic anxiety 3
• Research shows 15 mg/day is appropriate for mildly anxious patients, though highly anxious patients may require higher doses 5
• Long-term studies demonstrate sustained anxiolytic efficacy at 15-40 mg/day without tolerance development over 22 weeks 4

Important Caveats

Avoid common pitfalls:

• Regular use can lead to tolerance, addiction, depression, and cognitive impairment 2
• Paradoxical agitation occurs in approximately 10% of patients 2
• Always use gradual taper when discontinuing to reduce withdrawal reactions 1
• Infrequent, low doses of agents with short half-life are least problematic, though diazepam's longer half-life offers advantages for sustained anxiety control 2

Discontinuation Protocol

When stopping diazepam:

• Use gradual taper to reduce withdrawal risk 1
• If withdrawal reactions develop, pause the taper or increase back to previous dose level 1
• Then decrease more slowly 1
• Gradual tapering readily manages withdrawal reactions in all cases 4