Management of Benzodiazepine Withdrawal – WS DASSA August Benzodiazepine equivalents. Name. Duration of. Action #. Approx dose. Alprazolam. Xanax. Y**. B. Chlordiazepoxide Librium. Y**. B,E. Clonazepam. Klonopin. – N**. A,B,D,E. Diazepam. Valium. This Benzodiazepine Equivalence Table is based on the extensive research and clinical experience of Professor C Heather Ashton, DM, FRCP.
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This conversion tool estimates a reasonable equipotent dose between two benzodiazepines. Unlike opioid equipotent dosingbenzodiazepine equivalence is much less evidence-based and poorly described in the literature.
In fact, most benzodiazepine equivalence estimates are based on expert opinion, uncited tables in published documents, and clinical practice. All benzodiazepine conversions used in this calculator are based on published equipotent dose estimates.
The following guiding principles govern the calculator’s logic:. Due to discrepancies in the literature, many benzodiazepine conversions may have a potential conversion range that is extremely variable eg, by a factor of 10x or greater. These wide ranges of confidence highlight the lack of firm, evidence-based literature supporting specific conversion ratios.
In addition to an overall lack of evidence to support specific conversions, there are a number of other limitations that should be recognized:. Given the numerous issues with benzodiazepine equivalence, the importance of reasonable clinical judgment, clinical experience, appropriate patient monitoring, and dose titration are of even greater significance.
Most benzodiazepines included in this calculator are only available as oral dosage forms. Midazolam, lorazepam, diazepam, and phenobarbital are available in both parenteral and oral formulations. Because published benzodiazepine dose conversions are based on oral administration, parenteral formulations may not use the same conversion ratio. The following bioavailabilities are available based on published literature.
Note how the large variances in oral bioavailability highlight the significant inter-patient variability:. Unlike nearly all other benzodiazepine conversions, the conversion between intravenous midazolam and lorazepam has been well studied in mechanically ventilated patients. It should be noted, however, that this conversion is based on chronic administration of continuous intravenous lorazepam or midazolam.
Although phenobarbital and secobarbital are not benzodiazepines, they are commonly grouped with this drug class and cited within benzodiazepine conversion charts due to their use in alcohol withdrawal. While barbiturates do share similar pharmacology to benzodiazepines, they have a more concerning safety profile with a higher incidence of respiratory depression.
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Click here to start from scratch and enter your own patient data. Benzodiazepines have a narrow therapeutic window – dose adjustments should be made by an experienced clinician. This calculator is not a substitute for clinical experience and must be used in conjunction with reasonable clinical judgment. For more information, please view the website disclaimer. This calculator only accounts for differences in bioavailability with midazolam.
Management of withdrawal syndromes and relapse prevention in drug and alcohol dependence. A Comprehensive Study Guide. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital.
Can J Hosp Pharm. Dose equivalence of midazolam and triazolam. A psychometric study based on flicker sensitivity, reaction time and digit symbol substitution test. Eur J Clin Pharmacol. Lieberman JA, Tasman A.
Handbook of Psychiatric Drugs. How they work and how to withdraw; The Ashton Manual.
The Ashton Manual Online. Effect of age, gender, and obesity on midazolam kinetics.
COMPARISON OF BENZODIAZEPINES
Pharmacokinetics of midazolam following intravenous and oral administration in patients with chronic liver disease and in healthy subjects. Bioavailability of diazepam after intravenous, oral and rectal administration in adult epileptic patients. Br J Clin Pharmacol. Absolute bioavailability of oral and intramuscular diazepam: Phenobarbital pharmacokinetics and bioavailability in adults.
A double-blind, randomized comparison of i. Benzodiazepine Equivalents Conversion Calculator. Updated June 3, Accessed December 31, Home Academy Blog About. Diazepam Long Duration Variable.