THERAPEUTICS

Brands

• Valium
• Diastat
• see index for additional brand names

Generic?

• Yes (not Diastat)

Class

• Benzodiazepine (anxiolytic, muscle relaxant, anticonvulsant)

Commonly Prescribed For

• (bold for FDA approved)
• Anxiety disorder
• Symptoms of anxiety (short-term)
• Acute agitation, tremor, impending or acute delirium tremens and hallucinosis in acute alcohol withdrawal
• Skeletal muscle spasm due to reflex spasm to local pathology
• Spasticity caused by upper motor neuron disorder
• Athetosis
• Stiffman syndrome
• Convulsive disorder (adjunctive)
• Anxiety during endoscopic procedures (adjunctive) (injection only)
• Pre-operative anxiety (injection only)
• Anxiety relief prior to cardioversion (intravenous)
• Initial treatment of status epilepticus (injection only)
• Insomnia

How The Drug Works

• Binds to benzodiazepine receptors at the GABA-A ligand-gated chloride channel complex
• Enhances the inhibitory effects of GABA
• Boosts chloride conductance through GABA-regulated channels
• Inhibits neuronal activity presumably in amygdala-centered fear circuits to provide therapeutic benefits in anxiety disorders
• Inhibiting actions in cerebral cortex may provide therapeutic benefits in seizure disorders
• Inhibitory actions in spinal cord may provide therapeutic benefits for muscle spasms

How Long Until It Works

• Some immediate relief with first dosing is common; can take several weeks with daily dosing for maximal therapeutic benefit

If It Works

• For short-term symptoms of anxiety or muscle spasms – after a few weeks, discontinue use or use on an “as-needed” basis
• Chronic muscle spasms may require chronic diazepam treatment
• For chronic anxiety disorders, the goal of treatment is complete remission of symptoms as well as prevention of future relapses
• For chronic anxiety disorders, treatment most often reduces or even eliminates symptoms, but not a cure since symptoms can recur after medicine stopped
• For long-term symptoms of anxiety, consider switching to an SSRI or SNRI for long term maintenance
• If long-term maintenance with a benzodiazepine is necessary, continue treatment for 6 months after symptoms resolve, and then taper dose slowly
• If symptoms reemerge, consider treatment with an SSRI or SNRI, or consider restarting the benzodiazepine; sometimes benzodiazepines have to be used in combination with SSRIs or SNRIs for best results

If It Doesn’t Work

• Consider switching to another agent or adding an appropriate augmenting agent
• Consider psychotherapy, especially cognitive behavioral psychotherapy
• Consider presence of concomitant substance abuse
• Consider presence of diazepam abuse
• Consider another diagnosis, such as a comorbid medical condition

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Benzodiazepines are frequently used as augmenting agents for antipsychotics and mood stabilizers in the treatment of psychotic and bipolar disorders
• Benzodiazepines are frequently used as augmenting agents for SSRIs and SNRIs in the treatment of anxiety disorders
• Not generally rational to combine with other benzodiazepines
• Caution if using as an anxiolytic concomitantly with other sedative hypnotics for sleep

Tests

• In patients with seizure disorders, concomitant medical illness, and/or those with multiple concomitant long-term medications, periodic liver tests and blood counts may be prudent