Long-acting GABA-A PAM·Neurology - Sedatives & Hypnotics

DIAzepam

Acute anxiety, muscle spasms, alcohol withdrawal, status epilepticus

PBSBENZOValium, Antenex, Ducene2 mg tabletS4+1

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At a glance

Max Dose

Varies

Half-life

20–100 h

Caution: Dependence

HIGH RISK

Caution: Metabolites

ACTIVE

Cautions

Avoid / Cautions

Severe respiratory insufficiency, sleep apnea, Myasthenia Gravis. Pregnancy Category C (Risk of 'Floppy Infant Syndrome'). Avoid simultaneous parenteral administration with parenteral olanzapine (risk of fatal respiratory depression and severe hypotension).

Where it stands

Rapid Summary

Overview

Highly lipophilic, long-acting benzodiazepine. Rapid onset but features a massive half-life and active metabolites that accumulate in fat and liver tissue over days.

Clinical Focus

Do not use in the elderly or those with severe liver failure. The drug will accumulate, causing a multi-day coma and falls.

Bottom Line

Diazepam is a long-acting benzodiazepine for acute anxiety, seizures, and alcohol withdrawal, but accumulates with repeated dosing (active metabolites) and carries high dependence and respiratory depression risk.

Formulation & Access

Brand Names

Valium, Antenex, Ducene

Oral Routes

Tablets (2 mg, 5 mg).

Parenteral

Ampoules (10 mg/2 mL) for IV use. Avoid IM (erratic absorption and painful).

Prescribing & PBS

Unrestricted General Benefit (S4). High abuse potential.

Indications & Use

Primary

PBSTGA

Acute anxiety, muscle spasms, alcohol withdrawal, status epilepticus.

Clinical Place

The gold standard for alcohol withdrawal due to 'auto-tapering' (long half-life prevents sudden withdrawal seizures).

Quick reference

Class & Role

Long-acting GABA-A PAM — Highly lipophilic, long-acting benzodiazepine.

Route / Formulation

Tablets (2 mg, 5 mg). (Valium, Antenex, Ducene)

Usual Dose & Max

PO 2-10 mg BD to QID. Max varies entirely by indication (40 mg/day for anxiety, massive doses >100mg for acute alcohol withdrawal).

Key Indication Doses

Anxiety / Muscle Spasm: PO 2-10 mg BD to QID. Alcohol Withdrawal: PO 10-20 mg q1-2h PRN using a symptom-triggered CIWA-Ar scale. Status Epilepticus: IV 5-10 mg pushed slowly (2-5 mg/min). Max 20 mg. Elderly / Hepatic: Avoid or halve dose. Prefer Oxazepam or Lorazepam.

Best Uses

Key Risks

Neurological: Profound sedation, anterograde amnesia, ataxia, falls, cognitive blunting. CRITICAL — Tolerance, physical dependence, and severe withdrawal seizures upon abrupt cessation. Respiratory: Respiratory depression (especially if given rapidly IV or mixed with opioids). Cardiovascular: Hypotension (mostly IV).

Key Interactions

Opioids, Barbiturates, Alcohol. Additive and synergistic CNS/respiratory depression. Major cause of overdose deaths. CYP3A4 and CYP2C19 inhibitors (e.g., Omeprazole, Cimetidine) significantly prolong half-life.

Monitoring

Monitor SpO2 and RR if using IV. Assess for over-sedation and falls risk in all patients. No specific routine laboratory tests required.

Clinical Pearl

Diazepam is preferred in alcohol withdrawal because you load the patient with a massive dose on day 1 and 2, and then simply stop. The 100+ hour half-life of the metabolites tapers the drug out of the body naturally over a week, preventing seizures without needing complex weaning schedules.

Access

Valium, Antenex, Ducene2 mg tablet

Brand: Valium, Antenex, Ducene
Formulation: Tablets (2 mg, 5 mg).

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