BENZODIAZEPINES





Alprazolam (Xanax®)

Dosage forms

Tablet
  • 0.25 mg
  • 0.5 mg
  • 1 mg
  • 2 mg
Orally disintegrating tablet
  • 0.25 mg
  • 0.5 mg
  • 1 mg
  • 2 mg
Solution
  • 1 mg/ml
  • Comes in 30 ml bottles

Dosing

Anxiety disorders and transient anxiety
  • Starting: 0.25 - 0.5 mg three times a day as needed. Increase dose every 3 - 4 days as needed.
  • Maximum: 4 mg/day
  • Elderly: starting dose is 0.25 mg two to three times daily as needed. Increase dose gradually.
  • Liver disease: starting dose is 0.25 mg two to three times daily as needed. Increase dose gradually.
  • When discontinuing after chronic therapy, decrease daily dose by no more than 0.5 mg a day every 3 days

Pharmacokinetics

  • Peak plasma concentration: 1 - 2 hours
  • Half-life: 11.2 hours (range: 6.3 – 26.9 hours)
  • Average half-life is prolonged in elderly (16.3 hours), liver disease (19.7 hours), and obesity (21.8 hours)

Other


Generic / Price

  • Generic (30 tablets) - $
  • Generic (30 disintegrating tablets) - $-$$
  • Generic (30 ml solution) - $$

Alprazolam (Xanax XR®)

Dosage forms

Tablet, extended-release
  • 0.5 mg
  • 1 mg
  • 2 mg
  • 3 mg

Dosing

Panic disorder
  • Starting: 0.5 - 1 mg once daily. Increase dose every 3 - 4 days in increments of no more than 1 mg/day.
  • Maintenance: 3 - 6 mg once daily
  • Maximum: 10 mg once daily
  • Elderly: starting dose is 0.5 mg once daily. Increase dose gradually as needed.
  • Hepatic impairment: starting dose is 0.5 mg once daily. Increase dose gradually as needed.
  • When tapering off, decrease dose by no more than 0.5 mg/day every 3 days
Switching from Xanax to Xanax XR
  • Total daily Xanax dose may be given as once daily Xanax XR tablet

Pharmacokinetics

  • Xanax XR has the same pharmacokinetics as immediate-release Xanax except that it is absorbed more slowly. The slower absorption rate results in a relatively constant concentration that is maintained between 5 and 11 hours after the dosing.
  • High-fat meals increase the absorption of Xanax XR
  • Peak plasma concentration: 1 - 2 hours
  • Half-life: 11.2 hours (range: 6.3 – 26.9 hours)
  • Average half-life is prolonged in elderly (16.3 hours), liver disease (19.7 hours), and obesity (21.8 hours)


Other


Generic / Price

- YES/$

Chlordiazepoxide (Librium®)

Dosage forms

Capsule
  • 5 mg
  • 10 mg
  • 25 mg

Dosing

Anxiety
  • Mild-to-moderate: 5 - 10 mg three to four times a day as needed
  • Severe: 20 - 25 mg three to four times a day as needed
  • Elderly: 5 mg two to four times a day as needed
Alcohol withdrawal
  • Fixed dose regimen:
    • Day 1: 20 - 30 mg four times daily
    • Day 2: 20 - 30 mg three times daily
    • Day 3: 20 - 30 mg twice daily
    • Day 4: 20 - 30 mg at bedtime [2]
See NICE clinical guidelines on alcohol withdrawal for more

Pharmacokinetics

  • Peak plasma concentration: 2 hours
  • Half-life: 24 - 48 hours

Generic / Price

- YES/$

Chlordiazepoxide + clidinium (Librax®)

Dosage forms

Capsule
  • Chlordiazepoxide : clidinium
    • 5 mg : 2.5 mg

Dosing

Anxiety-related gastrointestinal disorders
  • 1 - 2 capsules three to four times a day as needed
  • Take before meals and at bedtime

Other


Generic / Price

- YES/$

Chlordiazepoxide + amitriptyline (Limbitrol®)

Dosage forms

Tablet
  • Chlordiazepoxide : amitriptyline
    • 5 mg : 12.5 mg
    • 10 mg : 25 mg

Dosing

Depression associated with anxiety
  • 3 or 4 tablets daily given in divided doses
  • Reduce dose to minimum effective dose
  • Do not exceed 6 tablets a day

Other


Generic / Price

- YES/$ (30 tablets)

Clobazam | Onfi® | Sympazan®

Dosage forms

Tablet (Onfi®)
  • 10 mg
  • 20 mg
Suspension (Onfi®)
  • 2.5 mg/ml
  • Comes in 120 ml bottle
Oral film (Sympazan®)
  • 5 mg
  • 10 mg
  • 20 mg
  • Film comes in a pouch
  • Comes in packages of 60 pouches

Dosing

Seizures associated with Lennox-Gastaut syndrome (≥ 2 years old)
  • Dosing is based on weight (see table below)
  • Doses > 5 mg/day should be given in divided doses twice daily. A 5 mg daily dose can be administered once daily.
  • Do not proceed with dose escalation more rapidly than weekly, because it takes 5 - 9 days to reach steady-state
  • Taper drug gradually by decreasing the daily dose 5 - 10 mg/day at weekly intervals
  • May take without regard to food
  • Tablets may be halved and crushed
  • Oral film (Sympazan) is applied on top of the tongue where it adheres and dissolves

≤ 66 pounds (30 kg) > 66 pounds (30 kg)
Starting dose 5 mg 10 mg
Starting Day 7 10 mg 20 mg
Starting Day 14 20 mg 40 mg

Elderly
  • Starting dose is 5 mg, and titration should occur at half the recommended dose
CYP2C19 Poor Metabolizers
  • Exposure to active metabolite is increased
  • Starting dose is 5 mg, and titration should occur at half the recommended dose
Liver disease
  • Child-Pugh A/B: starting dose is 5 mg, and titration should occur at half the recommended dose
  • Child-Pugh C: has not been studied. No recommendation given.
Kidney disease
  • CrCl ≥ 30 ml/min: no dose adjustment necessary
  • CrCl < 30 ml/min: has not been studied. No recommendation given.

Pharmacokinetics

  • Peak plasma concentration: 0.5 - 5 hours
  • Half-life:
    • Clobazam: 36 - 42 hours
    • Active metabolite: 71 - 82 hours

Other


Generic / Price

  • Tablet (#60) - YES/$
  • Suspension (120 ml) - YES/$$
  • Oral film (#60) - NO/$$$$

Clonazepam (Klonopin®)

Dosage forms

Tablet
  • 0.5 mg
  • 1 mg
  • 2 mg
Orally disintegrating tablet
  • 0.125 mg
  • 0.25 mg
  • 0.5 mg
  • 1 mg
  • 2 mg

Dosing - Adults

Panic disorder
  • Starting: 0.25 mg twice a day
  • Maintenance: 0.5 mg twice a day
  • Maximum: 2 mg twice a day
  • Increase in increments of 0.125 - 0.25 mg/dose at intervals of 3 days
  • Total daily dose may be given once daily at bedtime to minimize side effects
  • When discontinuing, decrease by 0.125 mg/dose every 3 days
Seizure disorder
  • Starting: 0.5 mg three times a day
  • Maximum: 20 mg/day
  • Increase in increments of 0.5 - 1 mg/day every 3 days

Dosing - Children

Seizure disorder (up to 10 years old or 30 kg)
  • Starting: 0.01 - 0.03 mg/kg/day given in 2 or 3 divided doses
  • Maintenance: 0.1 - 0.2 mg/kg/day given in 3 divided doses
  • Maximum: 0.2 mg/kg/day
  • Increase daily dosage by no more than 0.25 - 0.5 mg every third day

Pharmacokinetics

  • Peak plasma concentration: 1 - 4 hours
  • Half-life: 30 - 40 hours

Other


Generic / Price

- YES/$

Clorazepate (Tranxene®)

Dosage forms

Tablet
  • 3.75 mg
  • 7.5 mg
  • 15 mg

Dosing

Anxiety (adults)
  • Starting: 30 mg/day
  • Maintenance: 15 - 60 mg/day
  • Maximum: 60 mg/day
  • May be given 2 - 3 divided doses
  • In elderly or debilitated patients, consider initial daily dose of 7.5 to 15 mg
  • May take without regard to food
Acute alcohol withdrawal (adults)
  • First 24 hours: 30 mg initially; followed by 30 to 60 mg in divided doses
  • Second 24 hours: 45 to 90 mg in divided doses
  • Third 24 hours: 22.5 to 45 mg in divided doses
  • Day 4: 15 to 30 mg in divided doses
  • Day 5 and on: 7.5 - 15 mg/day until ready to discontinue
  • Maximum: 90 mg/day
  • May take without regard to food
Adjunct to Antiepileptic drugs (≥ 12 years)
  • Starting: 7.5 mg three times a day
  • Maximum: 90 mg/day
  • Dosage should be increased by no more than 7.5 mg every week
  • May take without regard to food
Adjunct to Antiepileptic drugs (9 - 11 years)
  • Starting: 7.5 mg two times a day
  • Maximum: 60 mg/day
  • Dosage should be increased by no more than 7.5 mg every week
  • May take without regard to food

Pharmacokinetics

  • Peak plasma concentration: ?
  • Half-life: 40 - 50 hours

Generic / Price

- YES/$

Diazepam (Valium®)

Dosage forms

Tablet
  • 2 mg
  • 5 mg
  • 10 mg
Solution
  • 1 mg/ml
Concentrate (Intensol)
  • 5 mg/ml

Dosing - Adults

Anxiety disorder
  • 2 - 10 mg two to four times a day as needed
Acute alcohol withdrawal
  • Day 1: 10 mg three to four times a day as needed
  • Day 2 and on: 5 mg three to four times a day as needed
Muscle spasm
  • 2 - 10 mg three to four times a day as needed
Seizure disorders (adjunctive treatment)
  • 2 - 10 mg two to four times a day as needed
Elderly patients
  • Starting: 2 - 2.5 mg one to two times a day as needed

Dosing - Children

Children ≥ 6 months old
  • Dosing: 1 - 2.5 mg three to four times a day as needed. Increase gradually as needed and tolerated.

Pharmacokinetics

  • Peak plasma concentration: 1 - 1.5 hours
  • Half-life:
    • Diazepam - up to 48 hours
    • Active metabolite - up to 100 hours
    • Half-life increases by approximately 1 hour for each year of age beginning with a half-life of 20 hours at 20 years of age

Other

  • Food slows absorption
  • Diazepam is a CYP3A4 and CYP2C19 sensitive substrate. Use caution with CYP3A4 and CYP2C19 inhibitors and inducers.

Generic / Price

  • Generic (30 tablets) - $
  • Generic (1 mg/ml, 180 ml) - $
  • Generic (5 mg/ml, 30 ml) - $

Diazepam (Diastat® AcuDial)

Dosage forms

Rectal gel
  • Comes in 2.5 mg, 10 mg, and 20 mg delivery system
  • 10 mg delivery system may be dialed to 5, 7.5, and 10 mg doses
  • 20 mg delivery system may be dialed to 12.5, 15, 17.5, and 20 mg doses
  • Comes in pack with 2 delivery systems

Dosing

Acute seizure (≥ 2 years old)
  • 2 - 5 years: 0.5 mg/kg
  • 6 - 11 years: 0.3 mg/kg
  • ≥ 12 years: 0.2 mg/kg
  • Dose should be rounded up to next available dose
  • A second dose may be given 4 - 12 hours after the first dose
  • It takes ∼ 3 minutes for therapeutic concentrations to reach the brain with the rectal route [13]

Pharmacokinetics

  • Peak plasma concentration: 1.5 hours
  • Half-life:
    • Diazepam - 46 hours
    • Active metabolite - 71 hours
  • It takes ∼ 3 minutes for therapeutic concentrations to reach the brain with the rectal route [13]

Other

  • Comes in a single dose rectal delivery system
  • Applicator can be dialed to appropriate dose
  • See patient instructions for proper delivery technique

Generic / Price

- YES/$$$-$$$$ (2 delivery systems)

Diazepam (Valtoco® nasal spray)

Dosage forms

Nasal spray device
  • 5 mg
  • 10 mg
  • 15 mg
  • 20 mg
  • Comes in carton with 2 devices

Dosing

Frequent seizure activity (≥ 6 years)
  • Dosing for Valtoco is based on age and weight and is presented in the table below
  • A second dose, when required, may be administered after at least 4 hours after the initial dose
  • Do not use more than 2 doses to treat a single episode
  • It is recommended that Valtoco be used to treat no more than one episode every five days and no more than five episodes per month

Dose Based on Age and Weight Administration
6 to 11 years
(0.3 mg/kg)
≥ 12 years
(0.2 mg/kg)
Dose (mg) Number of Devices Number of Sprays
10 to 18 kg 14 to 27 kg 5 One 5 mg device One spray in one nostril
19 to 37 kg 28 to 50 kg 10 One 10 mg device One spray in one nostril
38 to 55 kg 51 to 75 kg 15 Two 7.5 mg devices One spray in each nostril
56 to 74 kg ≥ 76 kg 20 Two 10 mg devices One spray in each nostril


Pharmacokinetics

  • Peak plasma concentration: 1.5 hours
  • Half-life (10 mg dose): 49.2 hours

Generic / Price

- NO/$$$$

Flurazepam (Dalmane®)

Dosage forms

Capsule
  • 15 mg
  • 30 mg

Dosing

Insomnia
  • 30 mg one time before bedtime as needed
  • 15 mg may be sufficient in elderly and debilitated patients

Pharmacokinetics

  • Peak plasma concentration: 30 - 60 minutes
  • Half-life:
    • Flurazepam: 2.3 hours
    • Active metabolite: 47 - 100 hours [3]

Generic / Price

- YES/$

Lorazepam (Ativan®)

Dosage forms

Tablet
  • 0.5 mg
  • 1 mg
  • 2 mg
Solution
  • 2 mg/ml
  • Comes in 30 ml bottle

Dosing

Anxiety
  • Starting: 2 - 3 mg/day given in two to three divided doses
  • Maintenance: 2 - 6 mg/day given in two to three divided doses
  • Elderly: 1 - 2 mg/day given in two to three divided doses
Insomnia
  • 2 - 4 mg given once at bedtime

Pharmacokinetics

  • Peak plasma concentration: 2 hours
  • Half-life: 12 hours
  • Lorazepam is metabolized by glucuronide conjugation
  • Liver and kidney disease only have a minor effect on lorazepam pharmacokinetics [4]

Other

  • Lorazepam is safe in breastfeeding [5]
  • Disulfiram (Antabuse®) does not appear to affect the metabolism of lorazepam [9]

Generic / Price

- YES/$

Oxazepam (Serax®)

Dosage forms

Capsule
  • 10 mg
  • 15 mg
  • 30 mg

Dosing

Mild-to-moderate anxiety
  • 10 - 15 mg three to four times a day as needed
Severe anxiety
  • 15 - 30 mg three to four times a day as needed
Alcohol withdrawal
  • 15 - 30 mg three to four times a day as needed
Elderly
  • Starting: 10 mg three times a day as needed
  • Maintenance: 15 mg three to four times a day as needed

Pharmacokinetics

  • Peak plasma concentration: 3 hours
  • Half-life: 8.2 hours
  • Oxazepam is metabolized by glucuronide conjugation

Other

  • Oxazepam is safe in breastfeeding [6]
  • Oxazepam is the short-acting metabolite of diazepam [6]
  • Disulfiram (Antabuse®) does not appear to affect the metabolism of oxazepam [9]

Generic / Price

- YES/$

Quazepam (Doral®)

Dosage forms

Tablet
  • 15 mg

Dosing

Insomnia
  • Starting: 7.5 mg once at bedtime
  • Maintenance: 7.5 - 15 mg once at bedtime

Pharmacokinetics

  • Peak plasma concentration: 2 hours
  • Half-life:
    • Quazepam: 39 hours
    • Active metabolite: 73 hours

Other

  • Tablet is scored so that it can be halved

Generic / Price

- NO/$$$$

Temazepam (Restoril®)

Dosage forms

Capsule
  • 7.5 mg
  • 15 mg
  • 22.5 mg
  • 30 mg

Dosing

Insomnia
  • Starting: 15 mg one time at bedtime
  • Maintenance: 7.5 - 30 mg one time at bedtime
  • Elderly: 7.5 mg one time at bedtime

Pharmacokinetics

  • Peak plasma concentration: 1.5 hours
  • Half-life (biphasic):
    • Short: 0.4 - 0.6 hours
    • Terminal: 8.8 hours

Other

  • Temazepam is a metabolite of diazepam [7]
  • Temazepam appears to be safe in breastfeeding [7]

Generic / Price

- YES/$

Triazolam (Halcion®)

Dosage forms

Tablet
  • 0.125 mg
  • 0.25 mg

Dosing

Insomnia
  • Starting: 0.25 mg once daily before bedtime
  • Maintenance: 0.125 - 0.5 mg once daily before bedtime
  • Max: 0.5 mg once daily before bedtime
  • Elderly: start with 0.125 mg once daily. Do not exceed 0.25 mg once daily.
  • A dosage of 0.125 mg once daily may be sufficient for some patients (e.g. patients with low body weight, elderly)

Pharmacokinetics

  • Peak plasma concentration: within 2 hours
  • Half-life: range of 1.5 - 5.5 hours

Other

  • Triazolam is a CYP3A4 sensitive substrate. Do not use with strong CYP3A4 inhibitors. Use caution with moderate and weak inhibitors.

Generic / Price

- YES/$





















Pricing legend
  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $150
  • Pricing based on 30 tablets unless otherwise specified
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability