Driving and skilled tasks May affect performance of skilled
tasks (e.g. driving); effects of alcohol may be enhanced.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
▶ Buspirone hydrochloride (Non-proprietary)
Buspirone hydrochloride 5 mg Buspirone 5mg tablets | 30 tablet P £13.30 DT = £3.70
Buspirone hydrochloride 10 mg Buspirone 10mg tablets | 30 tablet P £15.62 DT = £3.66
HYPNOTICS, SEDATIVES AND ANXIOLYTICS ›
apnoea syndrome . unstable myasthenia gravis
l CAUTIONS Avoid prolonged use (and abrupt withdrawal
thereafter). debilitated patients (reduce dose)(in adults).
elderly (reduce dose). history of alcohol dependence or
abuse . history of drug dependence or abuse . myasthenia
gravis . personality disorder (within the fearful group—
dependent, avoidant, obsessive-compulsive) may increase
risk of dependence .respiratory disease
▶ Paradoxical effects A paradoxical increase in hostility and
aggression may be reported by patients taking
benzodiazepines. The effects range from talkativeness and
excitement to aggressive and antisocial acts. Adjustment
of the dose (up or down) sometimes attenuates the
impulses. Increased anxiety and perceptual disorders are
disorders . withdrawal syndrome
▶ Uncommon Agitation (more common in children and
▶ Rare or very rare Aggression (more common in children
and elderly). blood disorder. delusions . jaundice . paradoxical drug reaction . psychosis
▶ Frequency not known Drug dependence
Overdose Benzodiazepines taken alone cause drowsiness,
ataxia, dysarthria, nystagmus, and occasionally respiratory
depression, and coma. For details on the management of
poisoning, see Benzodiazepines, under Emergency
treatment of poisoning p. 1359.
l PREGNANCY Risk of neonatal withdrawal symptoms when
used during pregnancy. Avoid regular use and use only if
there is a clear indication such as seizure control. High
doses administered during late pregnancy or labour may
cause neonatal hypothermia, hypotonia, and respiratory
l HEPATIC IMPAIRMENT In general, manufacturers advise
caution in mild to moderate impairment; avoid in severe
impairment. Benzodiazepines with a shorter half-life are
Dose adjustments In general, manufacturers advise dose
reduction in mild to moderate impairment, adjust dose
l RENAL IMPAIRMENT Increased cerebral sensitivity to
Driving and skilled tasks May cause drowsiness, impair
judgement and increase reaction time, and so affect ability
to drive or perform skilled tasks; effects of alcohol
increased. Moreover the hangover effects of a night dose
may impair performance on the following day.
For information on 2015 legislation regarding driving
whilst taking certain controlled drugs, including
benzodiazepines, see Drugs and driving under Guidance on
▶ Adult: 250–500 micrograms 3 times a day, increased if
necessary up to 3 mg daily, for debilitated patients, use
342 Mental health disorders BNF 78
▶ Elderly: 250 micrograms 2–3 times a day, increased if
with depression). obsessional states . phobic states . respiratory depression
l CAUTIONS Muscle weakness . organic brain changes
l INTERACTIONS → Appendix 1: alprazolam
mouth . memory loss . movement disorders . sexual
▶ Uncommon Menstruation irregular
oedema . photosensitivity reaction . suicide .thinking
l BREAST FEEDING Benzodiazepines are present in milk, and
should be avoided if possible during breast-feeding.
Dose adjustments Start with small doses in severe
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Alprazolam tablets are not prescribable in
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2
Alprazolam 250 microgram Xanax 250microgram tablets | 60
tablet P £3.18d Xanax 500microgram tablets | 60 tablet P £6.09d
Chlordiazepoxide hydrochloride
▶ Adult: 10 mg 3 times a day, increased if necessary to
60–100 mg daily in divided doses, for debilitated
▶ Elderly: 5 mg 3 times a day, increased if necessary to
30–50 mg daily in divided doses
Treatment of alcohol withdrawal in moderate dependence
▶ Adult: 10–30 mg 4 times a day, dose to be gradually
reduced over 5–7 days, consult local protocols for
Treatment of alcohol withdrawal in severe dependence
▶ Adult: 10–50 mg 4 times a day and 10–40 mg as
required for the first 2 days, dose to be gradually
reduced over 7–10 days, consult local protocols for
titration regimens; maximum 250 mg per day
with depression). obsessional states . phobic states . respiratory depression
l CAUTIONS Muscle weakness . organic brain changes
l INTERACTIONS → Appendix 1: chlordiazepoxide
▶ Common or very common Movement disorders
l BREAST FEEDING Benzodiazepines are present in milk, and
should be avoided if possible during breast-feeding.
Dose adjustments Manufacturer advises dose reduction to
max. 50% of the usual dose in mild to moderate
Dose adjustments Start with small doses in severe
l NATIONAL FUNDING/ACCESS DECISIONS
NHS restrictions Librium® is not prescribable in NHS
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Chlordiazepoxide hydrochloride (Non-proprietary)
Chlordiazepoxide hydrochloride 5 mg Chlordiazepoxide 5mg
Chlordiazepoxide hydrochloride 10 mg
capsules | 100 capsule P £11.50 DT = £
| 100 capsule P £17.80 DT = £17.80d
Chlordiazepoxide hydrochloride 5 mg Librium 5mg capsules | 100
Chlordiazepoxide hydrochloride 10 mg
capsule P £5.38 DT = £11.50dLibrium 10mg capsules | 100 capsule P £7.46 DT = £17.80d
Muscle spasm of varied aetiology
▶ Adult: 2–15 mg daily in divided doses, then increased if
necessary to 60 mg daily, adjusted according to
response, dose only increased in spastic conditions
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
▶ Adult: 10 mg, then 10 mg after 4 hours if required,
intravenous injection to be administered into a large
vein at a rate of no more than 5 mg/minute
▶ Child: 100–300 micrograms/kg every 1–4 hours
▶ Adult: 100–300 micrograms/kg every 1–4 hours
▶ BY INTRAVENOUS INFUSION, OR BY NASODUODENAL TUBE
▶ Child: 3–10 mg/kg, adjusted according to response, to
▶ Adult: 3–10 mg/kg, adjusted according to response, to
Muscle spasm in cerebral spasticity or in postoperative
▶ Child 1–11 months: Initially 250 micrograms/kg twice
▶ Child 1–4 years: Initially 2.5 mg twice daily
▶ Child 5–11 years: Initially 5 mg twice daily
▶ Child 12–17 years: Initially 10 mg twice daily; maximum
▶ Adult: 2 mg 3 times a day, then increased if necessary
to 15–30 mg daily in divided doses, for debilitated
▶ Elderly: 1 mg 3 times a day, then increased if necessary
to 7.5–15 mg daily in divided doses
Insomnia associated with anxiety
▶ Adult: 5–15 mg daily, to be taken at bedtime
Severe acute anxiety | Control of acute panic attacks |
▶ BY INTRAMUSCULAR INJECTION, OR BY SLOW INTRAVENOUS
▶ Adult: 10 mg, then 10 mg after at least 4 hours if
required, intravenous injection to be administered into
a large vein, at a rate of not more than 5 mg/minute
Acute drug-induced dystonic reactions
▶ Adult: 5–10 mg, then 5–10 mg after at least 10 minutes
as required, to be administered into a large vein, at a
rate of not more than 5 mg/minute
▶ Adult: 500 micrograms/kg, then 500 micrograms/kg
▶ Elderly: 250 micrograms/kg, then 250 micrograms/kg
▶ Adult: 5–10 mg, to be given 1–2 hours before
procedure, for debilitated patients, use elderly dose
▶ Elderly: 2.5–5 mg, to be given 1–2 hours before
▶ Adult: 100–200 micrograms/kg, to be administered into
a large vein at a rate of not more than 5 mg/minute,
Sedation in dental procedures carried out in hospital
▶ Adult: Up to 20 mg, to be given 1–2 hours before
Conscious sedation for procedures, and in conjunction
▶ Adult: 5–10 mg, to be given 1–2 hours before
procedure, for debilitated patients, use elderly dose
▶ Elderly: 2.5–5 mg, to be given 1–2 hours before
Sedative cover for minor surgical and medical procedures
▶ Adult: 10–20 mg, to be administered into a large vein
over 2–4 minutes, immediately before procedure
Status epilepticus | Febrile convulsions | Convulsions due
▶ Neonate: 300–400 micrograms/kg, then
300–400 micrograms/kg after 10 minutes if required, to
▶ Child 1 month–11 years: 300–400 micrograms/kg (max.
per dose 10 mg), then 300–400 micrograms/kg after
10 minutes if required, to be given over 3–5 minutes
▶ Child 12–17 years: 10 mg, then 10 mg after 10 minutes if
required, to be given over 3–5 minutes
▶ Adult: 10 mg, then 10 mg after 10 minutes if required,
administered at a rate of 1 mL (5 mg) per minute
▶ Neonate: 1.25–2.5 mg, then 1.25–2.5 mg after
▶ Child 1 month–1 year: 5 mg, then 5 mg after 10 minutes if
▶ Child 2–11 years: 5–10 mg, then 5–10 mg after
▶ Child 12–17 years: 10–20 mg, then 10–20 mg after
▶ Adult: 10–20 mg, then 10–20 mg after 10–15 minutes if
▶ Elderly: 10 mg, then 10 mg after 10–15 minutes if
Life-threatening acute drug-induced dystonic reactions
▶ Child 1 month–11 years: 100 micrograms/kg, repeated if
necessary, to be given over 3–5 minutes
▶ Child 12–17 years: 5–10 mg, repeated if necessary, to be
Dyspnoea associated with anxiety in palliative care
Pain of muscle spasm in palliative care
▶ With rectal use in children Diazepam Desitin ®, Diazepam
Rectubes ®, and Stesolid Rectal Tubes ® not licensed for use
Benzodiazepines should only be administered for
anaesthesia by, or under the direct supervision of,
personnel experienced in their use, with adequate
training in anaesthesia and airway management.
l CONTRA-INDICATIONS Avoid injections containing benzyl
alcohol in neonates . chronic psychosis (in adults). CNS
depression . compromised airway . hyperkinesis . not for
use alone to treat depression (or anxiety associated with
depression) (in adults). obsessional states . phobic states . respiratory depression
GENERAL CAUTIONS Muscle weakness . organic brain
changes . parenteral administration (close observation
required until full recovery from sedation)
▶ With intravenous use high risk of venous thrombophlebitis
with intravenous use (reduced by using an emulsion
▶ Special precautions for intravenous injection
▶ With intravenous use When given intravenously facilities for
reversing respiratory depression with mechanical
ventilation must be immediately available.
l INTERACTIONS → Appendix 1: diazepam
▶ Common or very common Appetite abnormal . concentration impaired . movement disorders . muscle
spasms . palpitations . sensory disorder. vomiting
▶ Uncommon Constipation . diarrhoea . hypersalivation . skin
▶ Rare or very rare Bradycardia . bronchial secretion
loss .respiratory arrest. sexual dysfunction . syncope
344 Mental health disorders BNF 78
▶ Frequency not known Apnoea . nystagmus
▶ With intravenous use Psychiatric disorder
▶ With oral use Psychiatric disorder
▶ With intramuscular use Chest pain; embolism and
thrombosis . fall . increased risk of dementia . psychiatric
disorders . soft tissue necrosis
l PREGNANCY Women who have seizures in the second half
of pregnancy should be assessed for eclampsia before any
change is made to antiepileptic treatment. Status
epilepticus should be treated according to the standard
Epilepsy and Pregnancy Register All pregnant women with
epilepsy, whether taking medication or not, should be
encouraged to notify the UK Epilepsy and Pregnancy
Register (Tel: 0800 389 1248).
l BREAST FEEDING Present in milk, and should be avoided if
possible during breast-feeding.
Dose adjustments Start with small doses in severe
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use Diazepam is adsorbed by plastics of
infusion bags and giving sets. Emulsion formulation
preferred for intravenous injection.
▶ With intravenous use in children For continuous intravenous
infusion of diazepam emulsion, dilute to a concentration of
max. 400 micrograms/mL with Glucose 5% or 10%; max.
6 hours between addition and completion of infusion. For
continuous intravenous infusion of diazepam solution,
dilute to a concentration of max. 50 micrograms/mL with
Glucose 5% or Sodium Chloride 0.9%.
▶ With intravenous use in adults For intravenous infusion
(solution) (Diazepam, Wockhardt), give continuously in
Glucose 5% or Sodium chloride 0.9%. Dilute to a
concentration of not more than 10 mg in 200 mL. For
intravenous infusion (emulsion) (Diazemuls ®), give
continuously in Glucose 5% or 10%. May be diluted to a
max. concentration of 200 mg in 500 mL; max. 6 hours
between addition and completion of administration. May
be given via drip tubing in Glucose 5% or 10% or Sodium
▶ With intramuscular use or intravenous use in adults Solution for
injection should not be diluted, except for intravenous
▶ With intramuscular use Only use intramuscular route when
oral and intravenous routes not possible.
l PRESCRIBING AND DISPENSING INFORMATION
Palliative care For further information on the use of
diazepam in palliative care, see www.medicinescomplete.
com/#/content/palliative/benzodiazepines-and-z-drugs.
l PATIENT AND CARER ADVICE Patients or carers should be
given advice on how and when to administer rectal
diazepam. Patients given sedatives and analgesics during
minor outpatient procedures should be very carefully
warned about the risks of undertaking skilled tasks (e.g.
driving) afterwards. For intravenous benzodiazepines the
risk extends to at least 24 hours after administration.
Responsible persons should be available to take patients
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