Adults

Dosage is highly individualized based on the patient's condition, age, co-medications, and the desired level of sedation. For procedural sedation, typically 0.02-0.1 mg/kg IV titrated slowly. For anesthesia induction, 0.3-0.35 mg/kg IV over 20-30 seconds.

Elderly

Reduced doses are recommended due to increased sensitivity and potential for prolonged effects. Typically, 25-50% of the usual adult dose.

Renal_impairment

Dose adjustment may be necessary in patients with severe renal impairment due to potential accumulation of active metabolites. Monitor closely for prolonged sedation.

Onset

IV: 1-5 minutes for sedation; IM: ~15 minutes.

Excretion

Excreted primarily via the kidneys as glucuronide conjugates of 1-hydroxymidazolam.

Half life

Distribution half-life: 6-15 minutes; Elimination half-life: 1.5-3.5 hours.

Absorption

Rapidly absorbed following intramuscular (IM) administration; bioavailability of IM is ~90%. Following intravenous (IV) administration, onset is rapid.

Metabolism

Extensively metabolized in the liver, primarily by cytochrome P450 3A4 (CYP3A4) isoenzyme, to its main active metabolite, 1-hydroxymidazolam, and inactive metabolites.

Opioids

Increased risk of profound sedation, respiratory depression, coma, and death. Avoid co-administration.

Alcohol and other CNS depressants

Additive CNS depressant effects. Avoid co-administration.

CYP3A4 inducers (e.g., Rifampin, Phenytoin, Carbamazepine, St. John's Wort)

Decrease midazolam plasma concentrations, reducing its effectiveness.

CYP3A4 inhibitors (e.g., Ketoconazole, Itraconazole, Erythromycin, Protease inhibitors, Diltiazem, Verapamil)

Increase midazolam plasma concentrations, prolonging and enhancing its effects. Dose reduction of midazolam may be necessary.