When to Order Diazepam (Valium)
Diazepam should be ordered for acute seizure management (status epilepticus), acute alcohol withdrawal, short-term anxiety relief (days to 2-4 weeks maximum), acute skeletal muscle spasm, and as adjunctive therapy in convulsive disorders—but never for chronic use beyond 4 weeks due to dependence risks. 1
Primary Indications for Diazepam
Acute Seizure Management (First-Line)
- Order rectal diazepam when IV access is unavailable for status epilepticus 2
- Order IV diazepam (or lorazepam if available) when IV access is present for acute seizure control 2
- Diazepam enters the brain within seconds to minutes after IV administration, making it highly effective for emergency seizure control 3
- For sustained seizure control, follow with IV phenobarbital or phenytoin after initial diazepam administration 2
- Consider prophylactic intermittent diazepam during febrile illness only for recurrent or prolonged complex febrile seizures, not for simple febrile seizures 2
Acute Alcohol Withdrawal (Preferred Agent)
- Order 10 mg orally 3-4 times daily during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 1
- Diazepam is the preferred benzodiazepine for moderate to severe alcohol withdrawal due to its shortest time to peak effect and longest elimination half-life, providing smoother withdrawal with lower breakthrough symptoms 4
- The long half-life of diazepam and its active metabolite creates a self-tapering effect, reducing rebound phenomena and possibly decreasing seizure risk 4
Short-Term Anxiety Management
- Order 2-10 mg orally 2-4 times daily depending on symptom severity 1
- Diazepam is indicated for acute stress reactions, episodic anxiety, fluctuations in generalized anxiety, and initial treatment of severe panic 5
- Limit prescriptions to single doses, very short courses (1-7 days), or short courses (2-4 weeks maximum) 5
- Long-acting benzodiazepines like diazepam are preferred for sustained levels of anxiety rather than episodic peaks 6
Skeletal Muscle Spasm
- Order 2-10 mg orally 3-4 times daily as adjunctive therapy 1
Insomnia (Alternative to First-Line Agents)
- Diazepam can be used in single or intermittent doses for transient or short-term insomnia 5
- However, benzodiazepines not specifically approved for insomnia (like diazepam) should only be considered if duration of action is appropriate or if comorbid conditions benefit from these drugs 2
Critical Contraindications—When NOT to Order
Absolute Contraindications
- Never order for patients concurrently taking opioids due to increased risk of respiratory depression and death 7
- Do not order for patients with history of alcohol or substance abuse due to significantly higher dependence risk 7
- Avoid in severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 7
High-Risk Situations Requiring Specialist Referral
- Refer patients with history of withdrawal seizures to a specialist rather than ordering routine diazepam 7
- Refer patients with co-occurring substance use disorders for specialist management 7
- Refer patients with unstable psychiatric comorbidities before continuing benzodiazepines 7
Dosing Adjustments
Geriatric or Debilitated Patients
- Start with 2-2.5 mg orally 1-2 times daily initially, then increase gradually as needed and tolerated 1
Pediatric Patients
- Do not use in children under 6 months 1
- Start with 1-2.5 mg orally 3-4 times daily in children ≥6 months, increase gradually as needed 1
Duration Limits and Monitoring
Maximum Duration Guidelines
- Prescriptions should be limited to 4 weeks maximum to prevent tolerance, dependence, and withdrawal complications including seizures and death 7, 5
- For insomnia specifically, limit to a few days, occasional/intermittent use, or courses not exceeding 2 weeks 5
Required Monitoring Before Each Refill
- Assess for signs of tolerance, which indicates need for discontinuation rather than refill 7
- Screen for concurrent substance use disorders, psychiatric comorbidities, and withdrawal history 7
- Evaluate for cognitive impairment and depression, which develop with regular use 7
- Check for concurrent CNS depressants including opioids 7
Discontinuation Protocol
When to Stop Ordering Refills
- Use gradual taper to discontinue: reduce by 25% of initial dose every 1-2 weeks for standard tapering 7, 1
- For use exceeding 6 years, extend taper over several months 7
- For use exceeding 1 year, reduce by 10% per month 7
- Never abruptly discontinue—this can cause seizures and death 7, 1
Adjunctive Medications During Taper
- Consider carbamazepine, pregabalin, buspirone, or gabapentin (100-300 mg starting dose) to mitigate withdrawal symptoms 7
Special Clinical Considerations
Route-Specific Guidance
- Do not order intramuscular diazepam due to erratic absorption from its lipophilicity 2, 4
- Use lorazepam or midazolam instead if IM administration is the only option 4