Anxiety Disorders, Preoperative Anxiolysis, Alcohol Withdrawal, and Musculoskeletal Conditions
Diazepam shares the actions of other benzodiazepines. The drug is used preoperatively to relieve anxiety and provide sedation, light anesthesia, and anterograde amnesia; as an adjunct during endoscopy to relieve anxiety and provide sedation, light anesthesia, and anterograde amnesia; for the management of agitation associated with acute alcohol withdrawal; as an adjunct for the relief of acute, painful musculoskeletal conditions; to manage 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, or tetanus; and for the management of anxiety disorders or for the short-term relief of symptoms of anxiety. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The efficacy of diazepam for long-term use (i.e., longer than 4 months) as an anxiolytic has not been evaluated.
Diazepam is also used IV or rectally as an anticonvulsant, and IV diazepam or lorazepam generally are considered the drugs of choice for termination of status epilepticus. Diazepam has been administered rectally either as a commercially available gel (e.g., Diastat) or using parenteral formulations. Although IV administration of benzodiazepines generally is preferred for the management of status epilepticus, rectal administration also may be useful for the treatment of status attacks, particularly for out-of-hospital management (e.g., at home or school, during transport to an emergency room). Rectal diazepam also may be particularly useful for the management of acute repetitive seizures (also referred to as serial, cyclic, cluster, breakthrough, or crescendo seizures), especially for out-of-hospital management. Acute repetitive seizures are exacerbations of an underlying seizure disorder that exhibit a pattern distinct from the patient's usual seizure pattern; the repetitive, periodic episodes often are predictable by the patient and caregivers according to a prodrome/aura, time of day when they originate, particular seizure type, and/or accompanying patient behavioral changes. Patients typically experience recovery between the repetitions; however, if untreated, acute repetitive seizures can evolve into more serious problems, including status epilepticus. The distinguishing features of these seizures are their predictability and pattern that differs from the underlying disorder rather than the actual seizure type; thus, while the pattern of presentation and patient and caregiver recognition are common features of the diagnosis, the actual seizure type can be different albeit definable for each individual patient.
In the 2 clinical studies establishing efficacy of rectal diazepam for the management of acute repetitive seizures in adults and children 2 years of age and older, the drug was more effective than placebo in reducing seizure frequency and improving global assessment of treatment outcome by caregivers (e.g., frequency and severity of seizures and patient tolerance of therapy). In these studies in adult and pediatric patients, the time to next seizure was prolonged in diazepam-treated patients relative to placebo, and about 55-62% of patients were seizure-free during the 12-hour observation period versus 20-34% for placebo recipients. In these studies, patients with a history of acute repetitive seizures that typically progressed to status epilepticus were excluded from study entry. Similar efficacy has been reported in other placebo-controlled and open-label studies. Although formal economic analyses have not been performed to date, patients treated with rectal diazepam out of the hospital required emergency medical treatment less commonly than did placebo recipients.
Sedation in Critical-care Settings
Diazepam has been used for the sedation of intubated and mechanically ventilated adults and children older than 12 years of age during treatment in a critical-care setting (e.g., an ICU). The drug is one of several benzodiazepines recommended for sedation of acutely agitated patients because of its rapid onset and short duration of action when given in single doses. However, prolonged duration of the sedative effect may occur with repeated doses, because of the presence of long-acting metabolites. Such longer duration of action may be acceptable in patients who require prolonged sedation.
Drug-induced Cardiovascular Emergencies
Diazepam has been used adjunctively in the management of certain drug-induced cardiovascular emergencies and cocaine-induced acute coronary syndrome.
Diazepam has been used orally to prevent night terrors. Although not recommended by the manufacturer, parenteral diazepam is used to reduce the requirements for opiate analgesics and produce anterograde amnesia during labor and delivery. The drug has been used parenterally to manage neonatal opiate withdrawal.