diazepam: clinical use

Prescribing considerations

• Confirm a licensed indication and discuss dependence, tolerance, withdrawal and the plan for ending treatment before prescribing where circumstances permit.
• Assess concurrent opioids, alcohol and other central nervous system depressants, as well as substance-use history and suicide risk.
• Older or debilitated people are more susceptible to accumulation, confusion, ataxia, falls and fractures.
• Use requires additional care in chronic respiratory disease and renal or hepatic dysfunction.
• Parenteral administration requires clinical observation and immediate access to resuscitation facilities.
• Review formulation excipients when treating children or people with relevant metabolic, allergy, dietary, hepatic or renal concerns.

Contraindications and cautions

• Hypersensitivity to diazepam, other benzodiazepines or formulation excipients
• Severe respiratory insufficiency or respiratory depression
• Sleep apnoea syndrome
• Myasthenia gravis or marked neuromuscular respiratory weakness
• Severe hepatic insufficiency
• Acute porphyria for the selected oral and injection products
• Use as sole treatment for depression or anxiety associated with depression
• Additional product-specific psychiatric and pregnancy contraindications apply; check the selected SmPC

Monitoring

• Level of consciousness, coordination and respiratory status, particularly with opioids or parenteral treatment
• Falls, confusion and paradoxical behavioural reactions in older people and children
• Signs of tolerance, escalating use, dependence, misuse and withdrawal
• Clinical response and ongoing need for treatment
• Hepatic, renal and respiratory factors that may increase accumulation or toxicity
• Cardiorespiratory status and local injection complications after parenteral administration

Clinical pharmacology

Diazepam enhances GABA-mediated inhibition through benzodiazepine-sensitive receptors. It is highly lipophilic and protein bound, is metabolised mainly through CYP3A4 and CYP2C19, and forms active metabolites including desmethyldiazepam, temazepam and oxazepam. Diazepam and its metabolites persist for a prolonged period, with slower elimination in neonates, older people and some patients with hepatic or renal impairment.

Formulation and product differences

• Tablets are for oral use and the selected product contains lactose.
• The oral suspension is raspberry flavoured, contains sucrose, parabens, colouring and a small amount of ethanol, and must be shaken before use.
• The injection contains substantial amounts of propylene glycol and ethanol and is intended for monitored parenteral use.
• The rectal solution is a rapid-absorption, single-use presentation containing benzyl alcohol, benzoates, ethanol and propylene glycol.

Oral suspension

Route: Oral

Strengths: 2 mg/5 mL

Tablet

Route: Oral

Strengths: 2 mg, 5 mg, 10 mg

Enema

Route: Rectal