Typical Dosing for Valium (Diazepam) in Adults
For acute anxiety or agitation, start with 2-5 mg orally 2-4 times daily, with a typical range of 5-40 mg/day divided into multiple doses; for alcohol withdrawal, use 20 mg orally every 1-2 hours until symptoms resolve (typically 3 doses over 7.6 hours); and for elderly or debilitated patients, begin with 2-2.5 mg once or twice daily and titrate gradually. 1
Standard Dosing by Indication
Anxiety Disorders
- Initial dose: 5 mg three times daily for most adults 2
- Typical maintenance range: 15-40 mg/day divided into multiple doses 3
- Alternative controlled-release: 10 mg once daily provides smooth 24-hour coverage with less morning/evening drowsiness compared to divided dosing 2
- Long-term use (up to 22 weeks) maintains efficacy without tolerance development 3
Alcohol Withdrawal
- Loading dose approach: 20 mg orally every 1-2 hours until asymptomatic 4
- Median effective treatment: 3 doses (60 mg total) given over 7.6 hours 4
- Range: 1-12 doses (20-240 mg) over 0.33-45 hours depending on severity 4
- This loading strategy leverages diazepam's long half-life for kinetic tapering, eliminating need for scheduled dosing 4
- 72% of patients respond within 6.3 hours with this approach 4
Acute Agitation/Crisis Management
- Parenteral dosing: 2.5 mg subcutaneous or intravenous every 1 hour as needed (maximum 5 mg per dose) 5
- Use lower doses (0.5-1 mg) in elderly, frail patients, or those with COPD 5
- Can also be administered intramuscularly, though this route has erratic absorption 1
Special Population Adjustments
Elderly and Debilitated Patients
- Start low: 2-2.5 mg orally 1-2 times daily initially 1
- Titrate gradually as needed and tolerated 1
- Higher risk of paradoxical excitement, agitation, or delirium 1
- Increased fall risk with all benzodiazepines 5
Hepatic Impairment
- Dose reduction mandatory in severe liver disease 1
- Diazepam undergoes hepatic metabolism with active metabolites accumulating over time 6
Respiratory Compromise
- Dose reduction mandatory in severe pulmonary insufficiency 1
- Reduce dose by 30% when co-administered with opioids due to synergistic respiratory depression 1
- Monitor oxygen saturation and respiratory effort closely, especially with rapid IV administration 1
Contraindications Requiring Extreme Caution
- Severe pulmonary insufficiency, severe liver disease, or myasthenia gravis require dose reduction or avoidance 1
- Avoid combining with high-dose olanzapine (fatalities reported) 5
Administration Considerations
Route Selection
- Oral preferred for most indications 4, 3, 2
- Avoid intramuscular injection due to erratic absorption and tissue necrosis risk 1
- Intravenous/subcutaneous reserved for acute crisis situations requiring rapid control 5
Monitoring Requirements
- Watch for respiratory depression, particularly with rapid IV administration or combination with other sedatives 1
- Monitor for paradoxical reactions (agitation, confusion) especially in elderly 1
- Assess for oversedation and adjust dose accordingly 7
Long-Term Use Considerations
Duration and Withdrawal
- Efficacy maintained without tolerance for at least 22 weeks of continuous use 3
- Withdrawal risk stratification:
- Withdrawal reactions are manageable by gradual dose tapering and are not life-threatening 3
- Long-term use (up to 16 years documented) does not lead to clear-cut abuse when used appropriately 6
Plasma Concentrations
- Total diazepam plus nordiazepam (active metabolite) ranges 0-2,584 ng/mL with long-term use 6
- Nordiazepam predominates due to diazepam's long half-life and active metabolism 6
Common Pitfalls to Avoid
- Do not delay treatment in alcohol withdrawal—complications occur only when therapy is delayed 4
- Do not use fixed scheduled dosing for alcohol withdrawal when loading dose strategy is more effective 4
- Do not combine with other CNS depressants without dose reduction 1
- Do not abruptly discontinue after prolonged use—taper gradually to prevent withdrawal 3