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Benzodiazepine / Antiepileptic Pregnancy: Avoid unless essential; neonatal withdrawal and respiratory depression.

Diazepam (Rectal)

Brand names: Stesolid, Rectioles

Adult dose

Dose: 10–20 mg rectally; IV: 10 mg at 2.5 mg/min
Route: Rectal or IV
Frequency: Single dose; may repeat once after 15 minutes
Max: 30 mg rectal; 20 mg IV per episode
Acute seizures/status epilepticus: 10 mg PR. If seizure persists >5 min, may give second dose. IV diazepam: 10 mg at 2.5 mg/min (have resuscitation equipment available). Rectal preferred out-of-hospital.

Paediatric dose

Dose: 0.5 mg/kg
Route: Rectal
Frequency: Single dose; may repeat once
Max: 10 mg/dose
Concentration: 2 mg/ml
1 month–1 year: 2.5 mg PR. 1–4 years: 5 mg PR. 5–11 years: 5–10 mg PR. 12–17 years: 10 mg PR. Weight-based: 0.5 mg/kg (max 10 mg). IV: 0.1–0.3 mg/kg at 1 mg/min (max 10 mg).

Dose adjustments

Renal

No dose adjustment required for acute use.

Hepatic

Use with caution — accumulation risk in hepatic impairment.

Paediatric weight-based calculator

1 month–1 year: 2.5 mg PR. 1–4 years: 5 mg PR. 5–11 years: 5–10 mg PR. 12–17 years: 10 mg PR. Weight-based: 0.5 mg/kg (max 10 mg). IV: 0.1–0.3 mg/kg at 1 mg/min (max 10 mg).

Clinical pearls

  • Rectal route preferred for pre-hospital and first-line community seizure management
  • Buccal midazolam now preferred in many UK guidelines due to ease of administration
  • Have bag-mask ventilation available when giving IV diazepam
  • Diazepam emulsion (Diazemuls) less thrombophlebitis than solution for IV use
  • Parents/carers of children with epilepsy should be trained in PR diazepam administration

Contraindications

  • Respiratory depression
  • CNS depression
  • Myasthenia gravis
  • Sleep apnoea
  • Severe hepatic impairment

Side effects

  • Respiratory depression (serious — have resuscitation ready)
  • Sedation
  • Hypotension
  • Amnesia
  • Paradoxical agitation (children)
  • Thrombophlebitis at IV site

Interactions

  • Other CNS depressants (opioids, alcohol) — additive respiratory depression
  • Sodium valproate — increases diazepam levels
  • Cimetidine — increases diazepam levels
  • Flumazenil — reversal agent

Monitoring

  • Respiratory rate
  • Oxygen saturation
  • Level of consciousness
  • Seizure resolution

Reference: BNFc; BNF; NICE CG137; BNFc; APLS guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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