Midazolam

Midazolam is a benzodiazepine used in medical settings for sedation and, in specific products, to stop seizures. This guide explains its uses, how it works, label-based dosing information, side effects, warnings, interactions, pregnancy and breastfeeding, and what is known about brands and prices in India. Different products, routes and countries are described separately. Not every product is approved for every use or available in every country.

Midazolam at a Glance

What Is Midazolam?

Midazolam is a short-acting benzodiazepine. Depending on the product, doctors use it to produce sedation, reduce anxiety, cause temporary memory loss around a procedure, or stop seizures. Injectable midazolam must be given by trained healthcare professionals, with appropriate monitoring and access to resuscitation equipment. It is not a routine long-term treatment for anxiety.

Take this medicine only as advised by your doctor or healthcare professional. Do not start, stop, or change the dose on your own.

How Does Midazolam Work?

Midazolam acts on the GABA-A receptor and increases the effect of GABA, a chemical messenger that slows nerve activity. This produces sedation, reduced anxiety, muscle relaxation and anticonvulsant effects.

Uses of Midazolam by Product

Which of these products are marketed in India was not confirmed from official Indian sources. Indian pharmacy listings found were for midazolam injection only.

Midazolam Dosage and Administration

Midazolam dosing is decided by a doctor and depends on the purpose, age, weight, general health, other medicines and the product. The figures below are from US labels (unless stated) and are for information only. They are not instructions for self-medication.

Injectable midazolam is given only by trained healthcare professionals, with appropriate monitoring and resuscitation equipment available.

Procedural sedation, adults (injection, US label)

• Healthy adults under 60: the label says to start with as little as 1 mg, with no more than 2.5 mg given over at least 2 minutes. A total above 5 mg is “not usually necessary.”
• Adults 60 or older, debilitated or chronically ill: no more than 1.5 mg over at least 2 minutes, and a total above 3.5 mg is not usually necessary.
• Allow 3 to 5 minutes between doses for the full effect to show.
• Intramuscular use before surgery: onset within about 15 minutes, peaking at 30 to 60 minutes.
• Induction of anaesthesia uses different, higher doses and is given only by anaesthesia teams.

Continuous infusion in intubated patients (US label)

• Adults: loading dose 0.01 to 0.05 mg/kg (about 0.5 to 4 mg), given slowly, followed by a maintenance infusion usually started at 0.02 to 0.10 mg/kg/hour.
• Neonates: an intravenous loading dose should not be used. Starting infusion rates are lower and depend on gestational age.
• Rapid injection should be avoided because of the risk of severe low blood pressure and seizures, particularly in neonates.

Children, intermittent intravenous sedation (injection, US label)

• Children under 6 months are particularly vulnerable to airway obstruction and breathing problems, and dosing is unclear.
• Ages 6 months to 5 years: initial dose 0.05 to 0.1 mg/kg, with the total usually not exceeding 6 mg.
• Ages 6 to 12 years: initial dose 0.025 to 0.05 mg/kg, with the total usually not exceeding 10 mg.

Status epilepticus, adults (Seizalam, intramuscular, US label)

• 10 mg into the thigh muscle, given by a healthcare professional trained in recognizing and treating status epilepticus. The label does not give a repeat-dose schedule.

Seizure clusters, age 12 and older (Nayzilam, nasal spray, US label, revised 1/2023)

• Initial dose: one 5 mg spray into one nostril.
• If needed, one more 5 mg spray into the opposite nostril after 10 minutes.
• Do not use more than 2 doses for a single episode.
• Do not give a second dose if the person has trouble breathing.
• The label advises treating no more than one episode every three days and no more than 5 episodes per month.
• Sedation and psychomotor effects generally begin within 10 minutes.
• Follow the prescribed seizure action plan. Call emergency services if the person is struggling to breathe or the plan says to.

Prolonged seizures in children (buccal midazolam, UK, GOSH leaflet)

• Doses are set by the child’s prescription and medical team, with syringe strengths of 2.5 mg, 5 mg, 7.5 mg and 10 mg.
• The leaflet says to call emergency services (999 in the UK) straight away if the child isn’t breathing or their lips turn blue.
• It also says that if buccal midazolam does not control a seizure within five minutes, caregivers should follow their doctor’s advice or call 999. This threshold comes from that leaflet and may differ in other plans and countries.

Take this medicine only as advised by your doctor or healthcare professional. Do not start, stop, or change the dose on your own.

Side Effects of Midazolam

Common (depends on the product):

• Drowsiness, dizziness, headache, confusion, and temporary memory loss
• With the nasal spray: headache, nasal discomfort, throat irritation, and runny nose
• With buccal midazolam: drowsiness, short-term memory loss, shallow breathing for a while, and sometimes restlessness or agitation

Serious side effects:

• Slow or shallow breathing, airway obstruction, or stopped breathing
• Low blood pressure
• Allergic reactions
• Rarely, cardiac or respiratory arrest
• Increased eye pressure in people with glaucoma (Nayzilam label)
• With seizure medicines such as Nayzilam, a labelled risk of suicidal thoughts or behavior

Get emergency help immediately if breathing is slow, shallow or stops, lips turn blue, or the person cannot be woken. Effects do not occur equally often with every product.

Midazolam Boxed Warnings and Serious Risks

US labels:

• Opioids: using benzodiazepines with opioids may cause profound sedation, respiratory depression, coma and death.
• Abuse, misuse and addiction: benzodiazepines expose users to these risks, which can lead to overdose or death (boxed on the Seizalam and Nayzilam labels).
• Dependence and withdrawal: with use more often than recommended, abrupt stopping or rapid dose reduction can cause life-threatening withdrawal reactions (boxed on the Seizalam and Nayzilam labels).
• Injectable products: the injection label’s boxed warning covers personnel and equipment for monitoring and resuscitation.

UK and Indian labels may differ. These boxed warnings are US label content.

Midazolam Contraindications and Precautions

Formal contraindications (differ by product label)

• Known allergy to midazolam: listed on the injection, Seizalam and Nayzilam labels
• Acute narrow-angle glaucoma: listed on the injection and Nayzilam labels, but not on the Seizalam label

Precautions (not formal contraindications):

• Older adults, debilitated patients and children need lower or adjusted doses.
• Rapid intravenous injection should be avoided.
• People with impaired consciousness or breathing vulnerability need close monitoring.
• Midazolam can impair memory, thinking and coordination for several hours. Do not drive, ride a bicycle or operate machinery until fully back to normal.
• Animal studies suggest that anaesthetic and sedative drugs, when used for longer than 3 hours, may cause long-term cognitive effects in young animals. The clinical significance in humans is not clear.

Midazolam Drug Interactions

• Opioids (such as morphine and fentanyl): greater risk of serious breathing problems, coma and death.
• Alcohol and other CNS depressants (such as barbiturates and droperidol): increased sedation. The Nayzilam label advises avoiding alcohol unless a provider approves.
• CYP3A4 inhibitors: the injection and Seizalam labels name erythromycin, diltiazem, verapamil, ketoconazole and itraconazole as agents that can prolong sedation. The Nayzilam label specifically advises avoiding moderate or strong CYP3A4 inhibitors. These medicines are not identical in effect or restriction.

Tell your doctor or pharmacist about all prescription medicines, OTC medicines, supplements and herbal products you use. This list is not complete.

Midazolam in Pregnancy and Breastfeeding

• Pregnancy: midazolam crosses the placenta. Use late in pregnancy can cause sedation in the newborn (breathing problems, drowsiness, low muscle tone) or withdrawal. Doctors weigh the benefit to the mother against possible risk to the baby, and label wording differs by product.
• Breastfeeding: midazolam passes into breast milk. Reports include sleepiness, poor sucking and poor feeding in breastfed infants. Labels differ: one injection label says a lactating woman may consider pumping and discarding milk for 4 to 8 hours after administration, while the Nayzilam label gives no such advice and asks that infants be monitored. Discuss this with your doctor.

Midazolam Brands and Price in India

Midazolam injection is a prescription medicine for use under medical supervision. Listings found were marked “prescription” and “not for online sale,” and several showed “sold out” or “not available.”

Prices differ between sources and are not confirmed current. The mg/mL concentration was not stated explicitly on any page. A 5 mg listing in a 5 mL vial implies 1 mg/mL, and the Apollo composition field says “1 MG,” but this is inferred, not verified. Do not treat the listed strength as concentration per mL or as total vial content until confirmed on the manufacturer’s label. Manufacturer information and 5 mg/mL products need verification. A price range is not published.

How HealthPil Can Help

Medicines should be started, adjusted, or stopped only under the guidance of a qualified healthcare professional. If you have questions about this medicine, its side effects, or your treatment plan, you can consult a doctor through HealthPil.