Brand names: Diastat, Valium
Drug class: Benzodiazepines
VA class: CN302
CAS number: 439-14-5

Medically reviewed by Drugs.com on Sep 28, 2022. Written by ASHP.

Introduction

Benzodiazepine; anticonvulsant, anxiolytic, sedative, and skeletal muscle relaxant.^{434 538 713 a}

Uses for Diazepam

Anxiety Disorders

Management of anxiety disorders and short-term relief of symptoms of anxiety.^{434 603 713 a b}

Preoperative or Preprocedural Sedation, Anxiolysis, and Amnesia

Used prior to surgery or other procedures (e.g., endoscopy, cardioversion) to produce sedation, anxiolysis, and anterograde amnesia.^{713 a}

Seizure Disorders

Treatment of status epilepticus and severe recurrent convulsive seizures.^{713 a b}

Benzodiazepines are considered initial drugs of choice for management of status epilepticus because of their rapid onset of action, demonstrated efficacy, safety, and tolerability.^{545 563 756 757 758 759 761 762 763 764 765 766 767 771} Evidence supports use of IV lorazepam, IV diazepam, or IM midazolam.^{545 763 764 765 766 767 768 769} Individualize choice of therapy based on local availability, route of administration, pharmacokinetics, cost, and other factors (e.g., treatment setting).^{545 756 757 758 759 760 761 762 763 764 765 766 767 769}

Rectal administration of diazepam may be useful for out-of-hospital management (e.g., at home or school, during transport to an emergency room) of status attacks and acute repetitive seizures (i.e., serial, cyclic, cluster, breakthrough, or crescendo seizures).^{543 545 546 547 548 549}

Oral diazepam has been used for adjunctive therapy of seizure disorders;^{434 b} however, loss of response to anticonvulsant effects may develop with prolonged use. (See Seizure Disorders under Cautions.)

Alcohol Withdrawal

Relief of agitation, tremor, impending or acute delirium tremens, and hallucinations associated with acute alcohol withdrawal.^{434 603 a b}

Skeletal Muscle Spasticity

Adjunct to rest, physical activity, analgesics, and other measures for relief of discomfort associated with acute, painful musculoskeletal conditions.^{a b}

Short- and long-term management of skeletal muscle spasticity such as reflex spasm secondary to local pathology (e.g., trauma, inflammation), spasticity caused by upper motor neuron disorders (e.g., cerebral palsy, paraplegia), athetosis, stiff-man syndrome, strychnine poisoning, and tetanus.^{434 603 a b}

Sedation in Critical Care Settings

Has been used for sedation of intubated and mechanically ventilated patients in critical care settings^{† [off-label]} (e.g., ICU).^{564 801}

Nonbenzodiazepine sedatives (dexmedetomidine and propofol) are generally preferred to benzodiazepines in mechanically ventilated, critically ill adults because of some modest clinical benefits that have been demonstrated (e.g., reduced duration of mechanical ventilation, shorter time to extubation, reduced risk of delirium).^{800 801} If a benzodiazepine is required, midazolam or lorazepam is preferred; diazepam is rarely used for this indication.⁸⁰¹

Night Terrors

Has been used effectively to prevent night terrors^{† [off-label]}.^{a b}

Drug-induced Cardiovascular Emergencies

Adjunct in the management of certain drug-induced cardiovascular emergencies^{† [off-label]}.⁶⁹⁶ May be beneficial adjunctively in patients with cocaine-induced acute coronary syndrome^{† [off-label]}.⁶⁹⁶

Neonatal Opiate Withdrawal

Relief of agitation in the management of neonatal opiate withdrawal^{† [off-label]}.^{a b}

Diazepam Dosage and Administration

General

• Use smallest effective dosage to avoid oversedation.^{a b}

• Consider long half-life of diazepam and its metabolites when making dosage adjustments (see Half-life under Pharmacokinetics).^{a b}

• In patients who have received prolonged (e.g., for several months) therapy, avoid abrupt discontinuance, since manifestations of withdrawal can be precipitated; gradually taper dosage.^a Do notdiscontinue abruptly in patients with a history of seizure disorder since seizures may be precipitated.^{a b}

• Periodically reassess usefulness for treatment of anxiety.^a Administer for shortest possible duration.^a

Administration

Administer orally,^{434 603 a} by IM or IV injection,^{713 a} or rectally.⁵³⁸

Oral Administration

Administer orally as tablets or oral solution.^{434 603}

Dilute oral concentrate solution (e.g., with water, juice, carbonated or soda-like beverages) or mix with semi-solid foods (e.g., applesauce, pudding) using the calibrated dropper provided by manufacturer.⁶⁰³ Stir the liquid or food mixture gently for a few seconds and then consume immediately; do not store mixture for future use.⁶⁰³

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer by slow IV injection.⁷¹³ Although the injection has been diluted prior to IV administration, this is not recommended since precipitation may occur.^{713 b} (See Compatibility under Stability.)

Equipment for resuscitation should be readily available whenever diazepam is administered IV.^{713 b} (See Respiratory and Cardiovascular Effects under Cautions.)

For IV injection, administer directly into a large vein; if this is not possible, inject the drug into the tubing of a flowing IV solution as close as possible to the vein insertion site.^{713 b}

Take care to avoid intra-arterial administration or extravasation.^{713 b}

Switch patient to oral therapy as soon as possible.^b

Do not mix or dilute with other solutions or drugs.⁷¹³ Administer premedications (e.g., atropine, scopolamine) in a separate syringe.⁷¹³

Rate of Administration

Adults: Administer IV injection slowly at rate not exceeding 5 mg/minute.^{713 b}

Children and infants ≥30 days of age: Administer IV injection slowly over 3 minutes.^{713 b}

IM Administration

May be administered as deep IM injection;^{713 a b} however, absorption may be slow and erratic.^{a b} IM route is rarely justified.^b

Rectal Administration

Administer rectally as the commercially available gel via delivery device (plastic applicator with a flexible molded tip) provided by manufacturer.⁵³⁸ Consult manufacturer’s labeling for specific instructions for administration of the rectal gel.⁵³⁸

Also has been administered rectally as the parenteral solution^† via a syringe and rectally inserted tubing or via lubricated tuberculin syringe (without a needle) inserted 4–5 cm into the rectum.^{544 549}

Commercially available gel is provided in prefilled syringe applicators containing 2.5, 10, or 20 mg of diazepam.⁵³⁸

Dose to be delivered by the AcuDial applicator is locked into the device prior to dispensing.^{538 602} If necessary, use 2 applicators to administer the prescribed dose.⁵³⁸

The 2.5-mg unit-dose applicator also may be used as a partial replacement dose (supplemental dose) for patients who partially expel the recommended dose^{538 540} within 5 minutes after administration.⁵⁴⁰

Dispensing

Pharmacist must dial in and lock the correct dose to be administered prior to dispensing Diastat AcuDial.^{538 602}

While holding the barrel of the applicator in one hand, turn the cap of the applicator to select the dose.^{538 602} After confirming that the dose visible in the display window is correct, lock the dose by grasping the locking ring and pushing upward to lock both sides of the ring.^{538 602} A green “ready” band becomes visible at the base of the applicator once the dose-locking ring is engaged.⁶⁰²

Repeat the process for each applicator to be dispensed.^{538 602}

Administration

Prior to administering the dose, check the diazepam gel expiration date, verify that the green “ready” band on the Diastat AcuDial applicator is visible, and verify the dose displayed in the AcuDial display window.^{538 602}

Remove the protective cap from the syringe and ensure that the seal pin is removed with the cap.⁵³⁸

Lubricate the rectal applicator tip with the water-soluble lubricant (jelly) provided by the manufacturer.^{538 544}

Turn the patient so that they are resting on their side facing the caregiver; the patient’s upper leg should be bent forward and the buttocks separated to expose the rectum.⁵³⁸ Insert the lubricated applicator tip into the rectum until the rim of the syringe is snug against the rectal opening; slowly push the plunger (counting aloud slowly to 3) until it stops (i.e., until the entire dose of the applicator has been expelled into the rectum).⁵³⁸ Count slowly to 3 before removing the syringe from the rectum; to prevent leakage of the administered dose, hold the buttocks together while again counting slowly to 3.⁵³⁸

Leave the patient on their side facing the caregiver, note the time the dose was given, and observe the patient.⁵³⁸

Disposal

Discard Diastat and Diastat AcuDial rectal delivery systems and all unused materials in the garbage in a safe place away from children; do not reuse.⁵³⁸

Prior to discarding AcuDial applicator in the garbage, dispose of any gel remaining in the applicator.⁵³⁸ With the applicator tip pointed over the sink or toilet, pull back and remove the plunger from the barrel; then, replace the plunger in the barrel and gently depress the plunger until it stops, forcing gel from the applicator.⁵³⁸ Flush toilet or rinse sink with water until gel is no longer visible.⁵³⁸

Dosage

Pediatric Patients

Anxiety Disorders

Oral

Children ≥6 months of age: Manufacturer recommends initial dosage of 1–2.5 mg 3 or 4 times daily.^{434 603} Increase dosage gradually as needed and tolerated.^{434 603}

IV

Some clinicians recommend 0.04–0.2 mg/kg; may repeat in 3–4 hours.^b Total dose should not exceed 0.6 mg/kg in an 8-hour period.^b

Preoperative Sedation, Anxiolysis, and Amnesia

IM

Children >2 years of age: 0.4 mg/kg has been administered 1–2 hours before surgery.^b

Seizure Disorders

Oral

6–15 mg daily (occasionally up to 30 mg daily) in divided doses has been used for adjunctive management of epilepsy.^b

IV or IM

IV administration is preferred; may use IM route if IV administration not possible.⁷¹³

Children 30 days to <5 years of age: Usual initial dose for status epilepticus or severe recurrent convulsant seizures is 0.2–0.5 mg; may repeat every 2–5 minutes up to a maximum total dose of 5 mg.^{563 713 771} May repeat therapy with diazepam in 2–4 hours if necessary.^b

Children ≥5 years of age: Usual initial dose for status epilepticus or severe recurrent convulsant seizures is 1 mg; may repeat every 2–5 minutes up to a maximum total dose of 10 mg.^{713 b} May repeat therapy with diazepam in 2–4 hours if necessary.⁷¹³

Rectal

Children 2–5 years of age: Initially, 0.5 mg/kg as rectal gel, rounded up to the next available dose (i.e., the next multiple of 2.5 mg).^{538 540 544} If necessary, repeat initial dose in 4–12 hours.^{538 540} Administration of a third dose is not recommended by the manufacturer.⁵³⁸

Children 6–11 years of age: Initially, 0.3 mg/kg as rectal gel, rounded up to the next available dose (i.e., the next multiple of 2.5 mg).^{538 540 544} If necessary, repeat initial dose in 4–12 hours.^{538 540} Administration of a third dose is not recommended by the manufacturer.⁵³⁸

Children ≥12 years of age: Initially, 0.2 mg/kg as rectal gel, rounded up to the next available dose (i.e., the next multiple of 2.5 mg).^{538 540 544} If necessary, repeat initial dose in 4–12 hours. ^{538 540} Administration of a third dose is not recommended by the manufacturer.⁵³⁸

For rectal administration of parenteral solutions^†, 0.5 mg/kg (up to 20 mg) has been used.^{545 546 547 549 601} Some clinicians state a second dose of 0.25 mg/kg may be administered in 10 minutes if needed.⁶⁰¹

Skeletal Muscle Spasticity

Oral

When used as a sedative or muscle relaxant in children, some clinicians recommend 0.12–0.8 mg/kg daily in 3 or 4 divided doses.⁶⁰¹

IV

Some clinicians recommend 0.04–0.3 mg/kg every 2–4 hours, not to exceed 0.6 mg/kg in an 8-hour period.^{601 b}

Tetanus

IM or IV

Children >30 days to 5 years of age: 1–2 mg.^{713 b} May repeat dose every 3–4 hours as needed.^{713 b}

Children >5 years of age: 5–10 mg.^{713 b} May repeat dose every 3–4 hours as needed.^{713 b}

Neonatal Opiate Withdrawal†

IM

0.5–2 mg has been administered every 8 hours, followed by gradual dosage reduction.^b

Adults

Anxiety Disorders

Oral

2–10 mg 2–4 times daily, depending on severity of symptoms.^{434 603}

IV or IM

Initially, 2–5 mg for moderate anxiety or 5–10 mg for severe anxiety; may repeat in 3–4 hours if necessary.^b

Preoperative or Preprocedural Sedation, Anxiolysis, and Amnesia

Preoperative Sedation

IM or IV

10 mg 1–2 hours before surgery (IM administration preferred);^{713 b} some clinicians recommend doses up to 20 mg.^b

Cardioversion

IV

5–15 mg 5–10 minutes before the procedure.^{713 b}

Endoscopy

IV

Titrate dosage to obtain desired sedative response (e.g., slurring of speech).^{713 b} Generally 10 mg or less is adequate, but up to 20 mg may be required, especially if opiates are not given concomitantly.^{713 b}

IM

If IV administration not possible, may give IM dose of 5–10 mg approximately 30 minutes prior to endoscopy.^{713 b}

Alcohol Withdrawal

Oral

10 mg 3 or 4 times during the first 24 hours, followed by 5 mg 3 or 4 times daily as needed.^{434 603}

IM or IV

Initially, 10 mg, then 5–10 mg in 3–4 hours if necessary.⁷¹³

Alternatively, some clinicians recommend 10 mg initially, followed by 10 mg at 20- to 30-minute intervals until patient is calm.^b

Seizure Disorders

Oral

2–10 mg 2–4 times daily for adjunctive management of seizure disorders.^{434 603}

IV or IM

IV administration is preferred; may use IM route if IV administration not possible.⁷¹³

Initially, 5–10 mg.⁷¹³ May repeat at 10- to 15-minute intervals, if necessary, up to a maximum total dose of 30 mg.⁷¹³ May repeat therapy with diazepam in 2–4 hours, if necessary.⁷¹³

Rectal

Initially, 0.2 mg/kg as rectal gel, rounded up to next available dose (i.e., the next multiple of 2.5 mg).^{538 540 544} If necessary, repeat initial dose in 4–12 hours.^{538 540} Administration of a third dose is not recommended by the manufacturer.⁵³⁸

For rectal administration of parenteral solutions^†, 0.5 mg/kg (up to 20 mg) has been used.^{545 546 547 548 549 601} Some clinicians state a second dose of 0.25 mg/kg may be administered after 10 minutes if needed.⁶⁰¹

Skeletal Muscle Spasticity

Oral

2–10 mg 2–4 times daily.^{434 b}

IM or IV

Initially, 5–10 mg; may repeat in 3–4 hours if necessary.^{713 b}

Higher doses (e.g., up to 20 mg) have been given every 2–8 hours for tetanus.^{713 b}

Sedation in Critical Care Settings†

IV

Loading dose of 5–10 mg, followed by intermittent injections of 0.03–0.1 mg/kg every 0.5–6 hours as needed.⁸⁰¹ Titrate dosage to desired level of sedation.^{800 801}

Night Terrors†

Oral

Doses of 5–20 mg at bedtime have been used.^b

Labor and Delivery†

IV

10–20 mg.^b

Prescribing Limits

Pediatric Patients

IV

Maximum initial dose of 0.25 mg/kg.^b

Seizure Disorders

Rectal

Maximum recommended frequency for administration by caregivers outside hospital is 1 treatment course every 5 days and 5 treatment courses per month.⁵³⁸

Adults

Anxiety Disorders

IV

Some clinicians recommend maximum dosage of 30 mg in an 8-hour period.^b

Seizure Disorders

Rectal

Maximum recommended frequency for administration by caregivers outside hospital is 1 treatment course every 5 days and 5 treatment courses per month.⁵³⁸

Special Populations

Hepatic Impairment

Reduce dosage;^a use smallest effective dose to avoid oversedation.^a

Renal Impairment

Use smallest effective dose to avoid oversedation.^a

Geriatric or Debilitated Patients

Oral:

Initially, 2–2.5 mg once or twice daily.^{434 b} Increase dosage gradually as needed and tolerated.^{434 b}

IV or IM:

Lower doses (e.g., 2–5 mg) usually recommended.⁷¹³ Increase dosage gradually.⁷¹³

Rectal:

Dosage to be administered should be adjusted downward for the commercially available rectal gel.^{538 540 544}

Other Populations

Use smallest effective dosage in debilitated patients and patients with low serum albumin concentrations.^b In debilitated patients, observe maximum geriatric dosages. (See Geriatric Patients under Dosage and Administration.)^{434 b}

Cautions for Diazepam

Contraindications

• Known hypersensitivity to diazepam or any ingredient in the formulation.^{b 434 538}

• Manufacturers state that diazepam is contraindicated in patients with acute angle-closure glaucoma, but may be administered to patients with open-angle glaucoma who are receiving appropriate therapy;^{434 538 713 b} however, clinical rationale for this contraindication has been questioned.^{a b}

Warnings/Precautions

Warnings

Concomitant Use with Opiates

Concomitant use of benzodiazepines, including diazepam, and opiates may result in profound sedation, respiratory depression, coma, and death.^{538 700 701 703 705 706 707} Substantial proportion of fatal opiate overdoses involve concurrent benzodiazepine use.^{538 700 701 705 706 707 711} (See Boxed Warning.)

Reserve concomitant use of diazepam and opiates for patients in whom alternative treatment options are inadequate.^{538 700 703} (See Specific Drugs and Laboratory Tests under Interactions.)

CNS Effects

Performance of activities requiring mental alertness and physical coordination may be impaired.^{434 a}

Concurrent use of other CNS depressants may cause additive or potentiated CNS depression.^{434 a b} (See Concomitant Use with Opiates under Cautions and also see Specific Drugs and Laboratory Tests under Interactions.)

Psychiatric Indications

Do not use in patients with depressive neuroses or psychotic reactions in which anxiety is not prominent.^{434 a}

Respiratory and Cardiovascular Effects

Possibility of apnea and/or cardiac arrest.⁷¹³ Use parenterally (particularly by IV route) with caution in elderly and debilitated patients and in patients with compromised respiratory function.^{713 a b 538} Do not administer diazepam injection to patients in shock or coma or to those with acute alcohol intoxication with depression of vital signs.⁷¹³

Consider possibility of respiratory depression with rectal administration.^{538 540 544 546 547 550 551} Out-of-hospital caregivers should avoid repeated administration at relatively short intervals (see Prescribing Limits under Dosage and Administration).^{538 547}

Equipment for resuscitation should be readily available whenever diazepam injection is administered.^{713 b}

Concomitant use of other CNS depressants may increase the risk of apnea.^{713 a}

Abuse Potential

Psychologic and physical dependence may occur following prolonged use.^a

Patients with a history of drug or alcohol dependence or abuse are at risk of habituation or dependence; use only with careful surveillance in such patients.^{434 538 a}

Withdrawal Syndrome

Abrupt discontinuance following chronic use may result in symptoms of withdrawal (similar to those observed with barbiturates and alcohol).^{434 713 a} More severe symptoms generally observed in patients receiving excessive doses over an extended period of time.⁷¹³

After prolonged therapy, avoid abrupt discontinuance and follow a gradual dosage tapering schedule.^{434 713}

Seizure Disorders

Abrupt withdrawal may be associated with a temporary increase in seizure frequency or severity.^{434 b}

Effect on seizure activity after IV administration is short-lived; repeated administration may be necessary.⁷¹³ Consider need for a longer-acting agent for continued seizure control.⁷¹³

Chronic daily use as an anticonvulsant may increase the frequency and/or severity of tonic-clonic seizures; may necessitate increase in dosage of other anticonvulsants.^{434 538 a} (See Prescribing Limits under Dosage and Administration.)

Tonic status epilepticus has been precipitated following IV administration to control absence status or Lennox-Gastaut syndrome status epilepticus.^{713 a}

Local Reactions Following Parenteral Administration

Potential for local reactions (e.g., pain, thrombophlebitis) following parenteral administration;^{713 a} possible tissue necrosis following intra-arterial administration.^a (See IV Administration under Dosage and Administration.)

Precautions Associated with Use of Rectal Gel

Only caregivers who are deemed competent to recognize seizure episodes suitable for treatment, make the decision to initiate treatment, administer the drug, monitor the patient, and assess adequacy of response should administer diazepam rectal gel.⁵³⁸

General Precautions

Suicide

Use with caution in depressed patients; potential for suicidal tendencies.^a Prescribe and dispense drug in the smallest feasible quantity.^a

Laboratory Testing

Perform blood counts and liver function tests periodically during long-term therapy.⁴³⁴

Specific Populations

Pregnancy

Category D.⁵³⁸

Lactation

Diazepam and its metabolites are distributed into milk;⁵³⁸ discontinue nursing or the drug.^a

Pediatric Use

Safety and efficacy of oral formulations not established in infants <6 months of age.^{434 b}

Safety and efficacy of parenteral formulations not established in infants ≤30 days of age.⁷¹³

Safety and efficacy of rectal diazepam not established via clinical studies in children <2 years of age; manufacturer states that gel is not recommended in infants <6 months of age.⁵³⁸

CNS depression in neonates may be prolonged because of apparent inability to convert drug to inactive metabolites.⁷¹³

Geriatric Use

Increased risk of adverse CNS effects.^a Clearance may be decreased.⁵³⁸ Use with caution.⁵³⁸ (See Geriatric Patients under Dosage and Administration.)

Hepatic Impairment

Clearance may be decreased.⁵³⁸ Use with caution.^{b 538} (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Clearance of metabolites may be decreased.⁵³⁸ Use with caution.^{b 538}

Common Adverse Effects

Drowsiness,^{434 b 538 713} ataxia,^{434 713 b} muscle weakness,⁷¹³ fatigue.^{434 713 b}

With parenteral therapy, local reactions (venous thrombosis, phlebitis) at injection site.⁷¹³

Drug Interactions

Metabolized by CYP2C19 and CYP3A4.⁵³⁸

Drugs Affecting Hepatic Microsomal Enzymes

CYP2C19 and CYP3A4 inducers or inhibitors: Potential pharmacokinetic interaction (altered diazepam elimination).^{434 538 a}

Specific Drugs and Laboratory Tests

Diazepam Pharmacokinetics

Absorption

Bioavailability

Apparently well absorbed following oral administration.^a

Absorption is slow and erratic following IM administration.^a

Rapidly and well absorbed following rectal administration as gel or solution; bioavailability averages 80–102%.^{538 539 540 543} Peak plasma concentrations attained within 1.5 hours following rectal administration of the gel in adults; absorption from gel may be more rapid in children.⁵³⁹

Onset

Onset of anticonvulsant, anxiolytic, or sedative action occurs in 1–5 minutes following IV administration.^a

Duration

Duration of anticonvulsant, anxiolytic, or sedative action is 15–60 minutes following IV administration.^a

Distribution

Extent

Apparently widely distributed into body tissues; crosses the blood-brain barrier.^a

Diazepam and its metabolites cross the placenta and are distributed into milk.^{713 a}

Plasma Protein Binding

Diazepam and desmethyldiazepam: 95–98%.^{a 538}

Elimination

Metabolism

Metabolized in the liver by CYP2C19 and CYP3A4 to active metabolites.^{a 538}

Elimination Route

Excreted principally in urine as inactive conjugates.^a

Half-life

Diazepam: 20–50 hours.^{538 a}

Metabolites: Desmethyldiazepam: 30–200 hours.^{538 a} Temazepam: 5–20 hours.^a Oxazepam: 3–21 hours.^a

Special Populations

In neonates and infants, half-life may be prolonged; half-life may be shorter in children ≥2 years of age and adolescents.⁵³⁸

Geriatric patients and patients with hepatic impairment may have prolonged elimination half-lives of diazepam⁵³⁸ and its metabolites.^a

Stability

Storage

Oral

Tablets

Tight, light-resistant containers at 15–30°C.⁴³⁴

Solution and Solution Concentrate

20–25°C.⁶⁰³ Protect from light.⁶⁰³

Parenteral

Injection

15–30°C.^b Protect from light; avoid freezing.^b

Rectal

Gel

25°C (may be exposed to 15–30°C).⁵³⁸

Compatibility

Parenteral

Addition of diazepam injection to an IV infusion solution or plastic syringes may result in adsorption of diazepam to the plastic container and tubing.^b

Solution CompatibilityHID

Drug Compatibility

Actions

• Effects appear to be mediated through the inhibitory neurotransmitter GABA; the site and mechanism of action within the CNS appear to involve a macromolecular complex (GABA_A-receptor-chloride ionophore complex) that includes GABA_A receptors, high-affinity benzodiazepine receptors, and chloride channels.^{320 358 359 360 361 362 363 364 365 366 367 368 369 370}

Advice to Patients

• Provide manufacturer's patient information (e.g., medication guide) to the patient each time diazepam tablets are dispensed.⁴³⁴

• Importance of taking only as prescribed; do not increase dosage or duration of therapy or abruptly discontinue drug unless otherwise instructed by a clinician.⁴³⁴

• Risk of potentially fatal additive effects (e.g., profound sedation, respiratory depression, coma) if used concomitantly with opiates either therapeutically or illicitly.^{700 703} Avoid concomitant use of opiate antitussives;^{700 704} also avoid concomitant use of opiate analgesics unless use is supervised by clinician.^{700 703}

• Potential for drug to impair mental alertness or physical coordination; use caution when operating machinery or performing hazardous tasks until effects on individual are known.^a

• Importance of caregivers understanding their role and obligations for administration of diazepam gel to individuals in their care; prescribers should routinely discuss all steps detailed in the manufacturer’s patient/caregiver information.⁵³⁸

• Upon receiving Diastat AcuDial from the pharmacy and again prior to administering a dose, importance of verifying accuracy of prescription (e.g., prescribed dose is visible in the applicator display window; green “ready” band is visible on each applicator).^{538 602}

• Importance of properly disposing of diazepam gel applicators.⁵³⁸

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and alcohol consumption.^{434 a} Importance of avoiding alcohol-containing beverages or products.^{434 a}

• Importance of informing clinicians about any concomitant illnesses, particularly depression.^{434 a}

• Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.^{434 538}

• Importance of informing patients of other important precautionary information.^{434 538 713} (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Subject to control under the Federal Controlled Substances Act of 1970 as a schedule IV (C-IV) drug.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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