Diazemuls
diazepam
Pharmacologic class: Benzodiazepine
Therapeutic class: Anxiolytic, anticonvulsant, sedative-hypnotic, skeletal muscle relaxant (centrally acting)
Controlled substance schedule IV
Pregnancy risk category D
Action
Produces anxiolytic effect and CNS depression by stimulating gamma-aminobutyric acid receptors. Relaxes skeletal muscles of spine by inhibiting polysynaptic afferent pathways. Controls seizures by enhancing presynaptic inhibition.
Availability
Injection: 5 mg/ml
Oral solution: 1 mg/ml, 5 mg/5 ml
Tablets: 2 mg, 5 mg, 10 mg
Indications and dosages
➣ Anxiety disorders
Adults: 2 to 10 mg P.O. two to four times daily, depending on symptom severity. Alternatively, for moderate anxiety, 2 to 5 mg I.V., repeated in 3 to 4 hours if needed. For severe anxiety, 5 to 10 mg I.V., repeated in 3 to 4 hours if needed.
Children age 6 months and older: 1 to 2.5 mg P.O. three to four times daily; may increase gradually as needed
➣ Before cardioversion
Adults: 5 to 15 mg I.V. 5 to 10 minutes before cardioversion
➣ Before endoscopy
Adults: Usually, 10 mg I.V. is sufficient; may be increased to 20 mg I.V. Alternatively, 5 to 10 mg I.M. 30 minutes before endoscopy.
➣ Status epilepticus and severe recurrent convulsive seizures
Adults: 5 to 10 mg I.V. slowly, repeated as needed q 10 to 15 minutes, to a maximum of 30 mg; may repeat regimen if needed in 2 to 4 hours. May give I.M. if I.V. delivery is impossible.
Children ages 5 and older: 1 mg I.V. slowly q 2 to 5 minutes, to a maximum of 10 mg; repeat in 2 to 4 hours if needed. May give I.M. if I.V. delivery is impossible.
Children over 1 month to 5 years: 0.2 to 0.5 mg I.V. slowly q 2 to 5 minutes, to a maximum of 5 mg I.V. May give I.M. if I.V. delivery is impossible.
➣ Muscle spasm associated with local pathology, cerebral palsy, athetosis, "stiff-man" syndrome, or tetanus
Adults: 2 to 10 mg P.O. three to four times daily. Or initially, 5 to 10 mg I.V. or I.M., repeated in 3 to 4 hours if needed. Tetanus may necessitate higher dosages.
Elderly or debilitated patients: Initially, 2 to 2.5 mg P.O. once or twice daily, increased gradually as needed and tolerated
Children ages 5 and older: 5 to 10 mg I.M. or I.V., repeated q 3 to 4 hours as needed to control tetanus spasm
Children over 1 month to 5 years: 1 to 2 mg I.M. or I.V. slowly, repeated q 3 to 4 hours as needed to control tetanus spasm
➣ Acute alcohol withdrawal
Adults: Initially, 10 mg P.O. three to four times during first 24 hours, decreased to 5 mg P.O. three to four times daily p.r.n. Or initially, 10 mg I.M. or I.V.; then 5 to 10 mg I.M. or I.V. in 3 to 4 hours p.r.n.
Off-label uses
• Panic attacks
• Adjunct to general anesthesia
Contraindications
• Hypersensitivity to drug, other benzodiazepines, alcohol, or tartrazine
• Coma or CNS depression
• Narrow-angle glaucoma
Precautions
Use cautiously in:
• hepatic dysfunction, severe renal impairment
• elderly patients
• pregnant or breastfeeding patients (use not recommended)
• children.
Administration
• Give P.O. dose with or without food.
See Administer I.V. infusion slowly into large vein, taking at least 1 minute for each 5 mg in adults or at least 3 minutes for each 0.25 mg/kg in children.
• Know that I.V. route is preferred over I.M. route because of slow or erratic I.M. absorption.
• Don't mix with other drugs or solutions in syringe or container.
• Enforce bed rest for at least 3 hours after I.V. injection.
• Give I.M. injection deeply and slowly into large muscle mass.
• If desired, mix oral solution with liquid or soft food.
Adverse reactions
CNS: dizziness, drowsiness, lethargy, depression, light-headedness, disorientation, anger, manic or hypomanic episodes, restlessness, paresthesia, headache, slurred speech, dysarthria, stupor, tremor, dystonia, vivid dreams, extrapyramidal reactions, mild paradoxical excitation
CV: bradycardia, tachycardia, hypertension, hypotension, palpitations, cardiovascular collapse
EENT: blurred vision, diplopia, nystagmus, nasal congestion
GI: nausea, vomiting, diarrhea, constipation, gastric disorders, difficulty swallowing, increased salivation
GU: urinary retention or incontinence, menstrual irregularities, gynecomastia, libido changes
Hematologic: blood dyscrasias including eosinophilia, leukopenia, agranulocytosis, and thrombocytopenia
Hepatic: hepatic dysfunction
Musculoskeletal: muscle rigidity, muscular disturbances
Respiratory: respiratory depression
Skin: dermatitis, rash, pruritus, urticaria, diaphoresis
Other: weight gain or loss, decreased appetite, edema, hiccups, fever, physical or psychological drug dependence or tolerance
Interactions
Drug-drug. Antidepressants, antihistamines, barbiturates, opioids: additive CNS depression
Cimetidine, disulfiram, fluoxetine, hormonal contraceptives, isoniazid, ketoconazole, metoprolol, propoxyphene, propranolol, valproic acid: decreased metabolism and enhanced action of diazepam
Digoxin: increased digoxin blood level, possible toxicity
Levodopa: decreased levodopa efficacy
Rifampin: increased metabolism and decreased efficacy of diazepam
Theophylline: decreased sedative effect of diazepam
Drug-diagnostic tests. Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, lactate dehydrogenase: increased levels
Neutrophils, platelets: decreased counts
Drug-herbs. Chamomile, hops, kava, skullcap, valerian: increased CNS depression
Drug-behaviors. Alcohol use: increased CNS depression
Patient monitoring
• Monitor vital signs and respiratory and neurologic status.
• Supervise ambulation, especially in elderly patients.
• Monitor CBC and kidney and liver function test results.
See Avoid sudden drug withdrawal. Taper dosage gradually to termination of therapy.
Patient teaching
• Inform patient he may take drug with or without food; recommend taking it with food if it causes stomach upset.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
See Tell patient to notify prescriber immediately if easy bruising or bleeding occurs.
• Instruct patient to move slowly when sitting up or standing, to avoid dizziness from blood pressure decrease. Advise him to dangle legs briefly before getting out of bed.
See Advise patient not to stop taking drug abruptly.
• Advise patient to avoid alcohol and other depressants such as sedatives while taking drug.
• Tell female patient not to take drug if she is pregnant or plans to breastfeed.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
diazepam
(dye-az-e-pam) diazepam,Diastat
(trade name),Diazemuls
(trade name),Valium
(trade name)Classification
Therapeutic: antianxiety agentsPharmacologic: benzodiazepines
Indications
- Anxiety Disorder,
- Athetosis,
- Anxiety relief prior to cardioversion (injection),
- Stiffman Syndrome,
- Preoperative sedation,
- Conscious sedation (provides light anesthesia and anterograde amnesia).
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (sedation)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | 30–60 min | 1–2 hr | up to 24 hr |
| IM | within 20 min | 0.5–1.5 hr | unknown |
| IV | 1–5 min | 15–30 min | 15–60 min† |
| Rectal | 2–10 min | 1–2 hr | 4–12 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- dizziness (most frequent)
- drowsiness (most frequent)
- lethargy (most frequent)
- depression
- hangover
- ataxia
- slurred speech
- headache
- paradoxical excitation
Ear, Eye, Nose, Throat
- blurred vision
Respiratory
- respiratory depression (life-threatening)
Cardiovascular
- hypotension (IV only)
Gastrointestinal
- constipation
- diarrhea (may be caused by propylene glycol content in oral solution)
- nausea
- vomiting
- weight gain
Dermatologic
- rashes
Local
- pain (IM)
- phlebitis (IV)
- venous thrombosis
Miscellaneous
- physical dependence
- psychological dependence
- tolerance
Interactions
Drug-Drug interaction
Alcohol, antidepressants, antihistamines, and opioid analgesics —concurrent use results in additive CNS depression.Cimetidine, hormonal contraceptives, disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, propranolol, or valproic acid may ↓ the metabolism of diazepam, enhancing its actions.May ↓ the efficacy of levodopa.Rifampin or barbiturates may ↑ the metabolism and ↓ effectiveness of diazepam.Sedative effects may be ↓ by theophylline.Concurrent use of ritonavir is not recommended.Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression.Route/Dosage
AntianxietyAvailability (generic available)
Nursing implications
Nursing assessment
- Monitor BP, pulse, and respiratory rate prior to and periodically throughout therapy and frequently during IV therapy.
- Assess IV site frequently during administration; diazepam may cause phlebitis and venous thrombosis.
- Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies.
- Conduct regular assessment of continued need for treatment.
- Geriatric: Assess risk of falls and institute fall prevention strategies.
- Anxiety: Assess mental status (orientation, mood, behavior) and degree of anxiety.
- Assess level of sedation (ataxia, dizziness, slurred speech) prior to and periodically throughout therapy.
- Seizures: Observe and record intensity, duration, and location of seizure activity. The initial dose of diazepam offers seizure control for 15–20 min after administration. Institute seizure precautions.
- Muscle Spasms: Assess muscle spasm, associated pain, and limitation of movement prior to and during therapy.
- Alcohol Withdrawal: Assess patient experiencing alcohol withdrawal for tremors, agitation, delirium, and hallucinations. Protect patient from injury.
- Lab Test Considerations: Evaluate hepatic and renal function and CBC periodically during prolonged therapy. May cause ↑ tranaminases and alkaline phosphatase. Flumazenil is an adjunct in the management of toxicity or overdose. (Flumazenil may induce seizures in patients with a history of seizures disorder or who are on tricyclic antidepressants.)
Potential Nursing Diagnoses
Anxiety (Indications)Impaired physical mobility (Indications)
Risk for injury (Side Effects)
Implementation
- Patient should be kept on bedrest and observed for at least 3 hr following parenteral administration.
- If opioid analgesics are used concurrently with parenteral diazepam, decrease opioid dose by 1/3 and titrate dose to effect.
- Use lowest effective dose. Taper by 2 mg every 3 days to decrease withdrawal symptoms. Some patients may require longer taper periods (mo).
- Oral: Tablets may be crushed and taken with food or water if patient has difficulty swallowing.
- Mix Intensol preparation with liquid or semisolid food such as water, juices, soda, applesauce, or pudding. Administer entire amount immediately. Do not store.
- Intramuscular: IM injections are painful and erratically absorbed. If IM route is used, inject deeply into deltoid muscle for maximum absorption.
Intravenous Administration
- Intravenous: Resuscitation equipment should be available when diazepam is administered IV.
- Diluent: For IV administration do not dilute or mix with any other drug. If direct IV push is not feasible, administer IV push into tubing as close to insertion site as possible. Continuous infusion is not recommended due to precipitation in IV fluids and absorption of diazepam into infusion bags and tubing. Injection may cause burning and venous irritation; avoid small veins.Concentration: 5 mg/mL.
- Rate: Administer slowly at a rate of 5 mg/min in adults. Infants and children should receive 1–2 mg/min. Rapid injection may cause apnea, hypotension, bradycardia, or cardiac arrest.
- Y-Site Compatibility: docetaxel, methadone, piperacillin/tazobactam, teniposide
- Y-Site Incompatibility: acetaminophen, acyclovir, alemtuzumab, alfentanil, amikacin, aminocaproic acid, aminophylline, amphotericin B cholesteryl, amphotericin B colloidal, amphotericin B lipid complex, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, azathioprine, aztreonam, azithromycin, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, caspofungin, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, dantrolene, dexamethasone, dexmedetomidine, dexrazoxane, diazoxide, digoxin, diltiazem, diphenhydramine, dopamine, doripenem, doxacurium, doxorubicin, doxorubicin liposomal, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fluconazole, fludarabine, fluorouracil, folic acid, foscarnet, furosemide, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol, heparin, hetastarch, hydralazine, hydrocortisone, hydroxycobalamin, hydroxyzine, idarubicin, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, ketorolac, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, magnesium chloride, mannitol, mechlorethamine, meperidine, meropenem, metaraminol, methotrexate, methoxamine, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, multivitamin, mycophenolate, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pancuronium, pantoprazole, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phenytoin, phytonadione, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, rocuronium, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, tacrolimus, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, vitamin B complex with C, voriconazole, zoledronic acid
- Rectal: Do not repeat Diastat rectal dose more than 5 times/mo or 1 episode every 5 days. Round dose up to next available dose unit.
- Diazepam injection has been used for rectal administration. Instill via catheter or cannula fitted to the syringe or directly from a 1-mL syringe inserted 4–5 cm into the rectum. A dilution of diazepam injection with propylene glycol containing 1 mg/mL has also been used.
- Do not dilute with other solutions, IV fluids, or medications.
Patient/Family Teaching
- Instruct patient to take medication as directed and not to take more than prescribed or increase dose if less effective after a few weeks without checking with health care professional. Review package insert for Diastat rectal gel with patient/caregiver prior to administration. Abrupt withdrawal of diazepam may cause insomnia, unusual irritability or nervousness, and seizures. Advise patient that sharing of this medication may be dangerous.
- Medication may cause drowsiness, clumsiness, or unsteadiness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Geriatric: Advise geriatric patients of increased risk for CNS effects and potential for falls.
- Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.
- Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.
- Emphasize the importance of follow-up examinations to determine effectiveness of the medication.
- Seizures: Patients on anticonvulsant therapy should carry identification describing disease process and medication regimen at all times.
Evaluation/Desired Outcomes
- Decrease in anxiety level. Full therapeutic antianxiety effects occur after 1–2 wk of therapy.
- Decreased recall of surgical or diagnostic procedures.
- Control of seizures.
- Decrease in muscle spasms.
- Decreased tremulousness and more rational ideation when used for alcohol withdrawal.