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Benzodiazepine (anxiolytic, sedative, muscle relaxant) Pregnancy: Avoid in first trimester. Neonatal withdrawal if used near term. 'Floppy infant' syndrome.

Diazepam (Anxiolytic/Sedative)

Brand names: Valium, Stesolid

Adult dose

Dose: Anxiety: 2–10 mg 2–4 times daily; Acute alcohol withdrawal: 10–20 mg oral every 6 hours (CIWA-guided); Muscle spasm: 2–5 mg TDS
Route: Oral or IV
Frequency: 2–4 times daily (anxiety); as needed (acute use)
Max: 30 mg/day (anxiety); 80–120 mg/day (severe acute alcohol withdrawal — specialist setting)
Anxiety: only short-term (2–4 weeks — tolerance and dependence risk). Alcohol withdrawal: CIWA-guided fixed-dose or symptom-triggered. Diazepam preferred for withdrawal (long-acting reduces seizure risk). Acute benzodiazepine: 10 mg IV at 2.5 mg/min for status epilepticus.

Paediatric dose

Dose: 0.1 mg/kg
Route: Oral or IV
Frequency: As needed
Max: 10 mg/dose
Concentration: 2 mg/ml
Sedation/anxiety in children: 0.1–0.3 mg/kg. Night terrors (1–5 years): 1–2 mg at night. Febrile convulsions: see diazepam_rectal entry. IV for acute seizures: 0.1–0.3 mg/kg at 1 mg/min.

Dose adjustments

Renal

No dose adjustment for acute use; caution with prolonged use in severe renal failure.

Hepatic

Avoid or use very cautiously in severe hepatic impairment (active metabolites accumulate).

Paediatric weight-based calculator

Sedation/anxiety in children: 0.1–0.3 mg/kg. Night terrors (1–5 years): 1–2 mg at night. Febrile convulsions: see diazepam_rectal entry. IV for acute seizures: 0.1–0.3 mg/kg at 1 mg/min.

Clinical pearls

  • Benzodiazepines for anxiety: maximum 2–4 weeks to avoid dependence (NHS England guidance)
  • Long half-life and active metabolites (desmethyldiazepam) — less abrupt withdrawal than short-acting BZDs
  • Alcohol withdrawal: CIWA protocol — reduce dose over 5–7 days
  • Never abruptly stop after prolonged use — risk of life-threatening withdrawal seizures
  • Z-drugs (zopiclone) have similar dependence profile — not significantly safer than BZDs

Contraindications

  • Respiratory depression
  • Sleep apnoea
  • Myasthenia gravis
  • Severe hepatic impairment
  • Phobia of benzodiazepines/past paradoxical reactions

Side effects

  • Sedation and cognitive impairment
  • Dependence and tolerance (even short-term use)
  • Respiratory depression (especially IV)
  • Paradoxical agitation (especially children/elderly)
  • Anterograde amnesia
  • Withdrawal syndrome (seizures, psychosis if abrupt cessation after long use)

Interactions

  • CNS depressants (opioids, alcohol, antipsychotics) — additive respiratory depression
  • CYP3A4 inhibitors (cimetidine, fluconazole, erythromycin) — increase diazepam levels
  • CYP3A4 inducers (rifampicin, carbamazepine) — reduce diazepam levels
  • Flumazenil — reversal (use in overdose with respiratory depression)

Monitoring

  • Level of sedation
  • Respiratory rate
  • Signs of dependence (if long-term)
  • Alcohol withdrawal: CIWA score

Reference: BNFc; BNF; NICE CG113 Generalised Anxiety; PHE Alcohol Withdrawal 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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