Benzodiazepines for treatment of procedural anxiety in adults

Benzodiazepine	Oral dose*^¶	Initial parenteral dose*^¶	Onset (minutes)
Alprazolam	0.5 mg	Not available	Oral: 15 to 30 (delayed with high fat meal)
Diazepam	2 to 10 mg	0.03 to 0.1 mg/kg intravenous (2 to 10 mg per dose)^Δ	Oral: 15 Intravenous: 2 to 5
Lorazepam	1 to 2 mg	0.02 to 0.04 mg/kg intravenous (1 to 4 mg per dose)	Oral: 15 to 30 Intravenous: ≤10 to 15
Midazolam	Oral midazolam is not recommended due to variable response and limited availability (intranasal dosing is provided in footnote^◊)	0.01 to 0.02 mg/kg intravenous (0.5 to 2 mg per dose)	Intranasal: ≤5 Intravenous: 1 to 3
Oxazepam	15 to 30 mg	Not available	Oral: 60 to 120
Temazepam	15 to 30 mg	Not available	Oral: 30 to 60

Some patients experience mild symptoms such as nausea, lightheadedness, fatigue, unsteadiness, or psychomotor impairment for up to 24 hours after the administration of sedative agents. This should be made clear to the patient and the patient should be warned not to drive until side effects have completely resolved. Refer to UpToDate topic review of procedural sedation in adults.
Equipment, medications, and personnel skilled in advanced cardiac life support and with knowledge of the effects of sedatives and reversal agents must be available for intravenous administration of benzodiazepines.
The approach to benzodiazepine selection is reviewed in accompanying text; refer to section on medication preferred or indicated.

* Individualization of dose: In most adults, a standard (non-weight based) dose at the lower end to middle of dose range shown in table is appropriate. However, patients with regular benzodiazepine or alcohol use leading to tolerance may need a dose in the upper end of the range. Approximately 50% reduction of dose is needed for older (>60 years) or debilitated adults, patients with low cardiac output, or those premedicated with opioid analgesics. If intravenous administration is used, a slow rate of administration (eg over 2 to 5 minutes or more) with frequent assessments of cardiorespiratory and sedative effects is recommended. In patients who are obese, standard, non-weight-based initial dosing is preferred. Standard adult doses are shown in parentheses following intravenous weight-based doses.
¶ Repeated dose(s) usually equal to one-half of initial dose may be needed 30 to 60 minutes after oral administration or 5 to 30 minutes after intravenous administration, based upon response and duration of procedure.
Δ Administer by slow intravenous push in a relatively large vein.
◊ 5 mg/mL midazolam injection solution may be administered intranasally at a dose of 1 to 4 mg^[1]. Onset is within 5 minutes. The injection solution is irritating to nasal passages.

Reference:

Hollenhorst J, Munte S, Friedrich L, et al. Using intranasal midazolam spray to prevent claustrophobia induced by MR imaging. AJR 2001; 176:865.

Courtesy of authors with additional data from Gan TJ. Pharmacokinetic and pharmacodynamic characteristics of medications used for moderate sedation. Clin Pharmacokinet 2006; 45:855 and Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.

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