Can Diazepam Be Given in Acute Anxiety Attack?
Yes, diazepam can be administered for acute anxiety attacks, but lorazepam is the preferred benzodiazepine when IV access is available due to its longer duration of action and more predictable pharmacokinetics. 1
Oral Diazepam for Acute Anxiety
For patients able to swallow, oral diazepam 2-10 mg can be given 2-4 times daily for management of acute anxiety symptoms. 2 This provides rapid relief with onset of action within 15-30 minutes. 3
Dosing Considerations:
- Standard adult dose: 2-10 mg orally, 2-4 times daily depending on severity 2
- Elderly or debilitated patients: Reduce to 2-2.5 mg, 1-2 times daily initially, then increase gradually as tolerated 2
- Maximum duration: Ideally limit to very short courses (1-7 days) or short courses (2-4 weeks maximum) 3
Alternative Benzodiazepine Options
When Patient Can Swallow:
Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours) is recommended by NICE guidelines for anxiety or agitation. 4 For elderly or debilitated patients, reduce to 0.25-0.5 mg (maximum 2 mg in 24 hours). 4
When IV Access Available:
Lorazepam is the preferred benzodiazepine for acute severe anxiety in emergency settings, with a typical starting dose of 0.02-0.04 mg/kg (≤2 mg) administered slowly over several minutes. 1 This preference is based on lorazepam's longer duration of action (1-24 hours vs 15-20 minutes for diazepam's anticonvulsant activity) and more predictable pharmacokinetics. 1, 5
When Patient Cannot Swallow:
Midazolam 2.5-5 mg subcutaneously every 2-4 hours as required is recommended. 4
Critical Safety Considerations
Respiratory Monitoring:
- Mandatory monitoring of oxygen saturation and respiratory effort during benzodiazepine administration 1
- Be prepared to support ventilation, as respiratory depression is more likely in patients with underlying respiratory disease or when combined with opioids 1
- Increased incidence of apnea when given rapidly IV or combined with other sedative agents 1
Avoid Concurrent Opioid Use:
Concurrent benzodiazepine prescription with opioid prescription is associated with a near quadrupling of risk for overdose death compared with opioid prescription alone. 4 Avoid prescribing benzodiazepines and opioids concurrently whenever possible. 4
Duration of Treatment
Short-term use only is justified for acute anxiety attacks. 3, 6 Prescriptions should be limited to:
- A few days for transient insomnia/anxiety 3
- Very short courses (1-7 days) for episodic anxiety 3
- Short courses (2-4 weeks maximum) for acute stress reactions 3
Long-term use is only justified in patients with chronic severe anxiety where symptomatic relief and improved functioning outweigh the risk of dependence. 6
Common Pitfalls to Avoid
- Do not abruptly discontinue after regular use: Use gradual taper to reduce risk of withdrawal reactions, rebound anxiety, and in rare cases seizures or delirium. 2, 7
- Do not underdose in true emergencies: While caution is warranted, inadequate dosing may fail to control severe acute anxiety. 1
- Do not ignore paradoxical reactions: Benzodiazepines may paradoxically cause or worsen agitation in some patients. 1
- Do not use as monotherapy for panic disorder: Benzodiazepines should be combined with psychotherapy (supportive or cognitive approaches) for optimal outcomes. 8
Clinical Advantages of Diazepam
Diazepam offers high efficacy, rapid onset of action, and low toxicity for acute anxiety. 3 It is particularly effective for sustained levels of anxiety rather than episodic peaks. 6 However, somatic symptoms respond better to diazepam than psychic symptoms. 7