midazolam (Rx)

Brand and Other Names:Seizalam, Versed (DSC)
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Dosing & Uses


Dosage Forms & Strengths

oral syrup: Schedule IV

  • 2mg/mL (generic)

injectable solution: Schedule IV

  • 1mg/mL (generic)
  • 5mg/mL (generic, Seizalam)

Preoperative Sedation/Anxiolysis With Anterograde Amnesia


  • 70-80 mcg/kg (dose range ~5 mg) 30-60 minutes before surgery (reduce 50% for chronically ill or geriatric patients)  


  • Initial: Usually 0.5-1 mg given over 2 minutes (not to exceed 2.5 mg/dose); wait 2-3 minutes to evaluate sedative effect after each dose adjustment; total dose >5 mg usually not necessary to reach desired sedation; use 30% less midazolam if patient premedicated with narcotics or other CNS depressants
  • Debilitated or chronically ill patients: 1.5 mg IV initially; may repeat with 1 mg/dose IV q2-3 min PRN; not to exceed cumulative dose of 3.5 mg; peak effect may be delayed in elderly, so increments should be smaller and rate of injection slower
  • Maintenance: 25% of initial effective dose PRN by slow titration; reduce 30% if premedicated with opiate (50% in elderly/chronically ill)



  • <55 years without premedication: 300-350 mcg/kg IV injection over 20-30 seconds; wait 2-3 minutes to evaluate sedative effect after each dose adjustment; may use increments of 25% of initial dose PRN to complete induction; may use up to 0.6 mg/kg total dose in resistant cases, but such dosing may prolong recovery  
  • >55 years without premedication and with no systemic disease, in a patient who is not weak: 300 mcg/kg over 20-30 seconds initially; wait 2-3 minutes to evaluate sedative effect after each dose adjustment
  • >55 years without premedication but presence of systemic disease or weak patient: 200-250 mcg/kg over 20-30 seconds usually enough; 0.15 mg/kg enough in some cases; wait 2-3 minutes to evaluate sedative effect after each dose adjustment
  • >55 years with premedication: 150-350 mcg/kg IV injection over 20-30 seconds; wait 2-3 minutes to evaluate sedative effect after each dose adjustment; a dose of 250 mcg/kg usually enough to achieve desired effect


  • May administer increments of 25% of induction dose PRN when there are signs that anesthetic effects are lightening

Sedation of Intubated/Ventilated Patients

Load: 10-50 mcg/kg (dose range 0.5-4 mg) slow IV injection or infusion over several minutes; repeat q5-15min PRN  

Maintenance: Initial, 20-100 mcg/kg/hr infusion; titrate up or down 25-50% PRN

Status Epilepticus

Seizalam: Indicated for treatment of status epilepticus in adults

10 mg IM

Dosing Considerations

Because it is water soluble, takes approximately 3 times longer than diazepam to peak EEG effects; thus, clinician must wait 2-3 minutes to fully evaluate sedative effects before initiating procedure or repeating dose

Has twice the affinity for benzodiazepine receptors that diazepam has

May be administered IM if unable to obtain vascular access

Anesthesia: Typical adult induction and maintenance doses may need to be decreased in some elderly patients by 20-50%, because the elderly overall are more susceptible to CNS depressants than is the general population

Organophophorous Poisoning (Orphan)

Orphan designation for treatment of seizures induced by organophosphorous insecticide poisoning


  • Meridian Medical Technologies, Inc., A Pfizer Company; 6350 Stevens Forest Road; Columbia, Maryland 21046

Dosage Forms & Strengths

syrup: Schedule IV

  • 2mg/mL (generic)

injectable solution: Schedule IV

  • 1mg/mL (generic)
  • 5mg/mL (generic)


500-750 mcg/kg PO once diluted by juice 20-30 minutes prior to procedure; not to exceed 20 mg  

100-150 mcg/kg IM; up to 500 mcg/kg used; not to exceed 10 mg


  • <6 months: Initial, 50 mcg/kg IV over 2-3 minutes; titrate with small increments to clinical effect; monitor closely; data are limited in nonintubated infants
  • 6 months-6 years: Initial, 50-100 mcg/kg IV over 2-3 minutes; repeat q2-3min PRN; may require up to 600 mcg/kg total dose; not to exceed 6 mg total dose
  • 6-12 years: Initial, 25-50 mcg/kg IV over 2-3 minutes; repeat q2-3min PRN; may require up to 400 mcg/kg; not to exceed 10 mg total dose

Anesthesia (Non-neonatal)

Loading dose: 50-150 mcg/kg IV over 2-3 minutes PRN to achieve desired effect  

Continuous infusion: 1-2 mcg/kg/min IV infusion

Anesthesia (Neonatal)

IV loading dose should not be used in neonates

Continuous infusion: 0.5 mcg/kg/min IV infusion  

Preoperative Sedation/Anxiolysis with Anterograde Amnesia

IM: 2-3 mg (~20-50 mcg/kg) 30-60 minutes before surgery; some elderly patients may respond to as little as 1 mg; onset is 15 minutes (peaking at 30-60 min)

IV (>60 years): 1-1.5 mg initially; not to exceed >1.5 mg in 2 min period; may repeat with 1 mg/dose q2-3min PRN; not to exceed cumulative dose of 3.5 mg; peak effect may be delayed in elderly, so increments should be smaller and rate of injection slower

IV maintenance: 25% of initial effective dose PRN by slow titration

Dosing Considerations

Because geriatric patients may have altered drug distribution and diminished hepatic and/or renal function, reduced doses of midazolam are recommended

IV and IM doses of midazolam should be decreased for elderly and for debilitated patients, and patients aged ≥70 yr may be particularly sensitive

Anesthesia: Typical adult induction and maintenance doses may need to be decreased in some geriatric patients by 20-50%, because they are more susceptible to CNS depressants than is the general population



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            Adverse Effects


            Decreased respiratory rate (23%)

            Apnea (15%)


            Drowsiness (1-5%)

            Seizure-like activity (1%)

            Nausea/vomiting (3%)

            Cough (1%)

            Pain at injection site (4-5%)

            Frequency Not Defined







            • Desaturation
            • Hypotension
            • Seizurelike activity
            • Nystagmus
            • Paradoxical reactions
            • Hiccoughs
            • Apnea


            Black Box Warnings

            Respiratory depression/arrest has been associated with use, especially when used for sedation in noncritical care settings

            Use lower end of dosing range in debilitated patients, including the elderly

            Do not administer by rapid IV injection in neonates (hypotension and seizures reported, especially when used concomitantly with fentanyl)

            Should be used only in settings (eg, hospital, ambulatory care settings, including physicians' or dentists' offices) that can provide continuous monitoring of respiratory and cardiac function; immediate availability of resuscitative drugs and age- and size-appropriate equipment for ventilation and intubations, as well as personnel trained in their use and skilled in airway management, should be ensured

            For deeply sedated patients, a dedicated individual other than the practitioner performing the procedure should monitor the patient throughout the procedure

            Use of the 1 mg/mL formulation or dilution of the 1 mg/mL or 5 mg/mL formulation is recommended to facilitate slower injection

            Adult dosing

            • The initial IV dose for sedation in adult patients may be as little as 1 mg but should not exceed 2.5 mg in a normal, healthy adult; lower doses are necessary for older (>60 years) or debilitated patients and for patients receiving concomitant narcotics or other CNS depressants; the initial dose and all subsequent doses should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect

            Pediatric dosing

            • Doses of sedative medications in pediatric patients must be calculated on a mg/kg basis, and initial doses and all subsequent doses should always be titrated slowly; the initial pediatric dose of midazolam for sedation/anxiolysis/amnesia is age, procedure, and route dependent.


            • Midazolam should not be administered by rapid injection in the neonatal population; severe hypotension and seizures have been reported following rapid IV administration, particularly with concomitant use of fentanyl

            General anesthetics and sedation drugs in young children and pregnant women

            • Brain development
              • Prolonged or repeated exposure may result in negative effects on fetal or young children’s brain development
              • Caution with use during surgeries or procedures in children younger than 3 yr or in pregnant women during their third trimester
              • Assess the risk:benefit ratio in these populations, especially for prolonged procedures (ie, >3 hr) or multiple procedures

            Risks from concomitant use with opioids

            Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death

            Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate

            Limit dosages and durations to the minimum required

            Follow patients for signs and symptoms of respiratory depression and sedation

            Inform patients and caregivers that potentially fatal additive effects may occur if drug is used with opioids and that such drugs should not be used concomitantly unless supervised by a health care provider

            Prescribers should advise caregivers that they expect to be informed immediately if a patient develops any new findings which are not typical of the patient’s characteristic seizure episode

            Addiction, abuse, and misuse

            On September 2020, FDA addressed serious risks of benzodiazepine addiction, abuse, and misuse, which can lead to overdose and death

            Physical dependence can occur when taken steadily for several days to weeks, even as prescribed

            Stopping abruptly or reducing dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening

            Abuse and misuse of benzodiazepines commonly involve concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes; before prescribing and throughout treatment, assess each patient’s risk for abuse, misuse, and addiction

            Assess each patient’s risk prior to prescribing and monitor regularly for the development of these conditions

            Risks of dependence and withdrawal increase with longer treatment duration and higher daily dose; although injection is indicated only for intermittent use, if used more frequently than recommended, abrupt discontinuation or rapid dosage reduction may precipitate acute withdrawal reactions, including seizures, which can be life-threatening; use gradual taper when discontinuing therapy to reduce withdrawal reactions risk


            Documented hypersensitivity

            Acute alcohol intoxication

            Acute narrow angle glaucoma

            Intrathecal/epidural use (formulations containing preservatives, such as, benzyl alcohol)

            Potent inhibitors of CYP3A4 including amprenavir, atazanavir, darunavir, indinavir, lopinavir, ritonavir, nelfinavir, ritonavir, saquinavir, tipranavir or oral or injectable midazolam with fosamprenavir


            Use caution in COPD, sleep apnea, renal/hepatic disease, open-angle glaucoma (questionable), depression, suicidal ideation, impaired gag reflex, heart failure, patients at risk of falls, or obese patients

            Anterograde amnesia reported with benzodiazepines

            Use caution in myasthenia gravis (allowable in limited circumstances)

            Use in narrow-angle glaucoma questionable

            May cause hypotension; may occur more frequently in patients receiving opioid analgesics

            Use caution in patient receiving other CNS depressants or psychoactive medications

            IV use in shock, coma, depressed respiration, patients who recently received other respiratory depressants not recommended

            Paradoxical reactions, including hyperactive or aggressive behavior reported

            Avoid extravasation of arterial formulation

            Does not protect against increases in heart rate or blood pressure

            May cause CNS depression and impair ability to perform hazardous tasks

            Not for use as antidepressant, analgesic, or antipsychotic agent

            Not for use in acute alcohol intoxication, shock, or coma

            Use of drug, particularly in patients at elevated risk of abuse, necessitates counseling about risks and proper use of drug along with monitoring for signs and symptoms of abuse, misuse, and addiction; do not exceed recommended dosing frequency

            Avoid or minimize concomitant use of CNS depressants and other substances associated with abuse, misuse, and addiction (eg, opioid analgesics, stimulants); advise patients on proper disposal of unused drug; if a substance use disorder is suspected, evaluate patient and institute (or refer them for) early treatment, as appropriate

            For patients treated more frequently than recommended, use a gradual taper to discontinue therapy (a patient-specific plan should be used to taper the dose), to reduce risk of withdrawal reactions

            Patients at an increased risk of withdrawal adverse reactions after benzodiazepine discontinuation or rapid dosage reduction include those who take higher dosages, and those who have had longer durations of use

            In some cases, benzodiazepine users have developed a protracted withdrawal syndrome with withdrawal symptoms lasting weeks to more than 12 months

            Do not inject by rapid bolus to neonates or for sedation


            • Associated with risk of potentially fatal respiratory depression and arrest
            • Wait 2-3 min to evaluate sedation before repeating dose
            • Monitor respiratory and cardiac function
            • Have resuscitative drugs and equipment available; must monitor respiratory and cardiovascular status while administering the drug IV

            Pregnancy & Lactation


            There are no adequate and well-controlled studies of midazolam intranasal in pregnant women

            Available data suggest benzodiazepines are not associated with marked increases in risk for congenital anomalies

            Clinical considerations

            • Exposure to benzodiazepines during the second and third trimesters of pregnancy or immediately prior to or during childbirth may increase risk for decreased fetal movement and/or fetal heart rate variability, floppy infant syndrome, dependence, and withdrawal
            • Clinical manifestations of withdrawal or neonatal abstinence syndrome may include hypertonia, hyperreflexia, hypoventilation, irritability, tremors, diarrhea, and vomiting

            Pregnancy registry

            • Encourage women prescribed midazolam intranasal during pregnancy to enroll in the North American Antiepileptic Drug (NAAED) pregnancy registry by calling 1-888-233-2334 or register at http://www.aedpregnancyregistry.org/

            Animal studies

            • Administration of midazolam to rats and rabbits during the period of organogenesis or to rats during late pregnancy and throughout lactation at doses greater than those used clinically did not result in any apparent adverse effects on development
            • However, published data for benzodiazepines suggest potential of neuronal cell death and long-term effects on neurobehavioral and immunological function in animals following prenatal or early postnatal exposure at clinically relevant doses


            Midazolam is excreted in human milk

            Studies assessing effects in the breastfed infant or on milk production/excretion have not been performed

            Postmarketing experience suggests that breastfed infants of mothers taking benzodiazepines may experience lethargy, somnolence, and poor sucking

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.



            Mechanism of Action

            Binds receptors at several sites within the CNS, including the limbic system and reticular formation; effects may be mediated through GABA receptor system; increase in neuronal membrane permeability to chloride ions enhances the inhibitory effects of GABA; the shift in chloride ions causes hyperpolarization (less excitability) and stabilization of the neuronal membrane


            Bioavailability: 36% (children); 40-50% (PO); >90% (IM)

            Onset: 15-20 min (IM, PO); 3-5 min (IV)

            Duration: 1-6 hr (IM)

            Duration of anterograde amnesia: 1 hr (IM); 20-40 min (IV)

            Peak plasma concentration: 90 ng/mL (IM)

            Peak effect: 0.5 hr (IM)

            Peak sedation: 30-60 min


            Protein bound: 97%

            Vd: 1.0-3.1 L/kg


            Metabolized by liver via CYP3A4

            Metabolites: 1-hydroxymethylmidazolam


            Half-life: 2-6 hr

            Total body clearance: 0.25-0.54 L/hr/kg

            Excretion: Urine (90%); feces (2%)



            IV Incompatibilities

            Additive: Aminophylline(?), amoxicillin

            Syringe: Dimenhydrinate, heparin, pentobarbital, perphenazine, prochlorperazine, ranitidine

            Y-site: Albumin, amoxicillin, amphotericin B cholSO4, ampicillin, bumetanide, butorphanol, ceftazidime, cefuroxime, clonidine, dexamethasone, dobutamine(?), foscarnet, fosphenytoin, furosemide, hydrocortisone, imipenem-cilastatin, methotrexate, nafcillin, omeprazole, Na-bicarbonate, thiopental, TMP-SMX

            IV Compatibilities

            Solution: D5W, D5/NS, NS

            Additive: Cefuroxime, cimetidine, ciprofloxacin, furosemide, gentamicin, hydrocortisone, hydromorphone, metronidazole, ranitidine

            Syringe: Alfentanil, atracurium, atropine, buprenorphine, butorphanol, chlorpromazine, cimetidine, diamorphine, diphenhydramine, droperidol, fentanyl, glycopyrrolate, hydromorphone, hydroxyzine, meperidine, metoclopramide, morphine, nalbuphine, ondansetron, promazine, promethazine, scopolamine, sufentanil, thiethylperazine, trimethobenzamide

            Y-site: Abciximab, amikacin, amiodarone, argatroban, atracurium, bivalirudin, Ca-gluconate, cefazolin, cefotaxime, cimetidine, ciprofloxacin, cisatracurium, clindamycin, digoxin, diltiazem, dopamine, epinephrine, erythromycin, esmolol, etomidate, famotidine, fenoldopam, fentanyl, fluconazole, gatifloxacin, gentamicin, haloperidol, heparin, hetastarch, hydromorphone, insulin, labetalol, linezolid, lorazepam, methadone, methylprednisolone, metronidazole, milrinone, morphine, nicardipine, nitroglycerin, norepinephrine, pancuronium, piperacillin, KCl, propofol, ranitidine, remifentanil, sodium nitroprusside, sufentanil, theophylline, tirofiban, tobramycin, vancomycin, vecuronium

            IV Preparation

            Solution: 100 mg in 250 mL D5W or NS

            IV Administration

            Administered via infusion pump

            Give slowly over at least 2 min

            And wait at least 2 min when adjusting doses to desired effect

            Excessive dose or too rapid infusion may cause respiratory arrest

            Have resuscitation equipment available and monitor patient closely until effects of IV administration are known

            May dilute 1 mg/mL or 5 mg/mL in D5W or NS to facilitate slow injection

            IVP: Administer through side port of free-flowing IV

            Pediatric patients

            • As a group, pediatric patients generally require higher dosages of midazolam (mg/kg) than do adults
            • Younger (age <6 yr) may require higher dosages (mg/kg) than older pediatric patients, and may require close monitoring
            • Obese pediatric patients: Calculate dose based on ideal body weight


            • Do not administer by rapid injection; severe hypotension and seizures reported, particularly with concomitant fentanyl use

            IV monitoring

            • Monitor for irritation and infiltration
            • Extravasation can cause tissue damage and necrosis

            IM Administration

            Deep into large muscle mass

            Seizalam: For IM injection only; inject in mid-outer thigh (vastus lateralis muscle)


            Unopened vials: Store at 20-25ºC (68-77ºF); excursions permitted to 15-30ºC (59-86ºF)





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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
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            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
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