diazemuls


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Related to diazemuls: diazepam

diazepam

Apo-Diazepam (CA), Bio-Diazepam (CA), Dialar (UK), Diastat, Diazemuls (CA) (UK), Diazepam Intensol, Novo-Dipam (CA), PMS-Diazepam (CA), Stesolid (UK), Tensium, Valclair (UK), Valium, Vivol (CA)

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.

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.

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.

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.

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) ,

Diastat

(trade name),

Diazemuls

(trade name),

Valium

(trade name)

Classification

Therapeutic: antianxiety agents
Pharmacologic: benzodiazepines
Pregnancy Category: D

Indications

Adjunct in the management of:
  • Anxiety Disorder,
  • Athetosis,
  • Anxiety relief prior to cardioversion (injection),
  • Stiffman Syndrome,
  • Preoperative sedation,
  • Conscious sedation (provides light anesthesia and anterograde amnesia).
Treatment of status epilepticus/uncontrolled seizures (injection).Skeletal muscle relaxant.Management of the symptoms of alcohol withdrawal.Anxiety associated with acute myocardial infarction, insomnia.

Action

Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter.
Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways.
Has anticonvulsant properties due to enhanced presynaptic inhibition.

Therapeutic effects

Relief of anxiety.
Sedation.
Amnesia.
Skeletal muscle relaxation.
Decreased seizure activity.

Pharmacokinetics

Absorption: Rapidly absorbed from the GI tract. Absorption from IM sites may be slow and unpredictable. Well absorbed (90%) from rectal mucosa.
Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk.
Metabolism and Excretion: Highly metabolized by the hepatic P450 enzymes (CYP2C19 and CYP3A4); the CYP2C19 enzyme system exhibits genetic polymorphism; genetic implication 15–20% of Asian patients and 3–5% of Caucasian and Black patients may be poor metabolizers and may have significantly ↑ diazepam concentrations and an ↑ risk of adverse effects. Some products of metabolism are active as CNS depressants.
Half-life: Neonates: 50–95 hr; Infants 1 mo–2 yr: 40–50 hr; Children 2–12 yr: 15–21 hr; Children 12–16 yr: 18–20 hr; Adults: 20–50 hr (up to 100 hr for metabolites).

Time/action profile (sedation)

ROUTEONSETPEAKDURATION
PO30–60 min1–2 hrup to 24 hr
IMwithin 20 min0.5–1.5 hrunknown
IV1–5 min15–30 min15–60 min†
Rectal 2–10 min1–2 hr 4–12 hr
†In status epilepticus, anticonvulsant duration is 15–20 min

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Cross-sensitivity with other benzodiazepines may occur;Comatose patients;Myasthenia gravis;Severe pulmonary impairment;Sleep apnea;Severe hepatic dysfunction;Pre-existing CNS depression;Uncontrolled severe pain;Angle-closure glaucoma;Some products contain alcohol, propylene glycol, or tartrazine and should be avoided in patients with known hypersensitivity or intolerance; Obstetric: ↑ risk of congenital malformations; Pediatric: Children <6 mo (for oral; safety not established); Lactation: Recommend to discontinue drug or bottle-feed.
Use Cautiously in: Severe renal impairment;History of suicide attempt or drug dependence;Debilitated patients (dose ↓ required);Patients with low albumin; Pediatric: Metabolites can accumulate in neonates. Injection contains benzyl alcohol which can cause potentially fatal gasping syndrome in neonates; Geriatric: Long-acting benzodiazepines cause prolonged sedation in the elderly. Appears on Beers list and is associated with ↑ risk of falls (↓ dose required or consider short-acting benzodiazepine).

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

Antianxiety
Oral (Adults) 2–10 mg 2–4 times daily.
Intramuscular Intravenous (Adults) 2–10 mg, may repeat in 3–4 hr as needed.
Oral (Children >6 mo) 1–2.5 mg 3–4 times daily.
Intramuscular Intravenous (Children >1 mo) 0.04–0.3 mg/kg/dose q 2–4 hr to a maximum of 0.6 mg/kg within an 8 hr period if necessary.
Precardioversion
Intravenous (Adults) 5–15 mg 5–10 min precardioversion.
Pre-endoscopy
Intravenous (Adults) 2.5–20 mg.
Intramuscular (Adults) 5–10 mg 30 min pre-endoscopy.
Pediatric Conscious Sedation for Procedures
Oral (Children >6 mo) 0.2–0.3 mg/kg (not to exceed 10 mg/dose) 45–60 min prior to procedure.
Status Epilepticus/Acute Seizure Activity
Intravenous (Adults) 5–10 mg, may repeat q 10–15 min to a total of 30 mg, may repeat regimen again in 2–4 hr (IM route may be used if IV route unavailable); larger doses may be required.
Intramuscular Intravenous (Children ≥5 yr) 0.05–0.3 mg/kg/dose given over 3–5 min q 15–30 min to a total dose of 10 mg, repeat q 2–4 hr.
Intramuscular Intravenous (Children 1 mo–5 yr ) 0.05–0.3 mg/kg/dose given over 3–5 min q 15–30 min to maximum dose of 5 mg, repeat in 2–4 hr if needed.
Intravenous (Neonates) 0.1–0.3 mg/kg/dose given over 3–5 min q 15–30 min to maximum dose of 2 mg.
Rectal (Adults and Children >12 yr) 0.2 mg/kg; may repeat 4–12 hr later.
Rectal (Children 6–11 yr) 0.3 mg/kg; may repeat 4–12 hr later.
Rectal (Children 2–5 yr) 0.5 mg/kg; may repeat 4–12 hr later.
Febrile Seizure Prophylaxis
Oral (Children >1 mo) 1 mg/kg/day divided q 8 hr at first sign of fever and continue for 24 hr after fever is gone.
Skeletal Muscle Relaxation
Oral (Adults) 2–10 mg 3–4 times daily.
Oral (Geriatric Patients or Debilitated Patients) 2–2.5 mg 1–2 times daily initially.
Oral (Children >6 mo) 1–2.5 mg 3–4 times daily.
Intramuscular Intravenous (Adults) 5–10 mg; may repeat in 2–4 hr (larger doses may be required for tetanus).
Intramuscular Intravenous (Geriatric Patients or Debilitated Patients) 2–5 mg; may repeat in 2–4 hr (larger doses may be required for tetanus).
Intramuscular Intravenous (Children ≥5 yr) Tetanus—5–10 mg q 3–4 hr.
Intramuscular Intravenous (Children >1 mo) Tetanus—1–2 mg q 3–4 hr.
Alcohol Withdrawal
Oral (Adults) 10 mg 3–4 times in first 24 hr, ↓ to 5 mg 3–4 times daily.
Intramuscular Intravenous (Adults) 10 mg initially, then 5–10 mg in 3–4 hr as needed; larger or more frequent doses have been used.
Psychoneurotic Reactions
Intramuscular Intravenous (Adults) 2–10 mg, may be repeated in 3–4 hr.

Availability (generic available)

Tablets: 2 mg, 5 mg, 10 mg Cost: Generic — 2 mg $7.51 / 100, 5 mg $10.74 / 100, 10 mg $10.84 / 100
Oral solution: 1 mg/mL, 5 mg/mL (Intensol) Cost: Generic — 1 mg/mL $2.44 / 5 mL, 5 mg/mL $33.98 / 30 mL
Injection: 5 mg/mL (contains 10% alcohol and 40% propylene glycol)
Rectal gel delivery system: 2.5 mg, 10 mg, 20 mg

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.

Diazemuls

A brand name for DIAZEPAM.

diazemuls