Midazolam (Versed®) Dosage

Dr. Sheridan Walter
Dr. Jennie Stanford
Written by Dr. Sheridan Walter on 29 May 2025
Medically reviewed by Dr. Jennie Stanford on 29 May 2025

Midazolam (Versed®) is a short-acting benzodiazepine that can relax a person for a brief procedure, keep a ventilated patient settled, or stop a cluster seizure within minutes. Because the drug reaches the brain so quickly, small dose changes or the wrong drug combination can notably slow breathing and lower blood pressure.

The information below outlines the doses most frequently used, how doses are adjusted, and the steps that are necessary for safe use.

Key takeaways:
  • Dose slowly and reassess. Midazolam is given in 0.5 to 1 mg increments intravenously, with at least a few minutes between doses to assess response. Adults aged 65 years and older usually require about half the amount used for younger patients.
  • The route determines the speed. A single 10 mg intranasal dose (one 5 mg spray in each nostril) stops most cluster seizures in less than 10 minutes, while a slow IV infusion can keep ICU patients calmly ventilated for days.
  • Mixing depressants is the most significant risk. Opioids, alcohol, or potent CYP3A4 blockers (such as ketoconazole) can turn a routine dose into a respiratory emergency.
a photo of a hand holding a syringe filled Midazolam (Versed®), the person is checking the dosage

What is midazolam used for?

Versed® has multiple approved indications, including:

  • Short medical or dental procedures (such as an endoscopy or wisdom tooth extraction)
  • Induction or augmentation of general anesthesia
  • Continuous sedation during mechanical ventilation
  • Emergency control of cluster seizures when oral medication administration isn’t feasible or an intravenous (IV) line is not available
  • Relief of severe agitation or breathlessness in patients nearing the end of life

Methods of administration

Midazolam can be delivered in several ways, depending on the urgency, setting, and patient age. Intravenously administered midazolam acts within minutes, but it requires close monitoring. Other forms of midazolam, such as buccal or intranasal sprays, are designed for rapid seizure control outside hospital settings. The table below outlines the main methods and how quickly they take effect.

Route and settingHow quickly it works
IV push (hospital or outpatient procedure center)1–2 minutes
IV infusion (in intensive care unit settings)About 5 minutes to reach a steady level
Intramuscular injection (ambulance or home kit)About 15 minutes
Intranasal spray (seizure rescue, usually for individuals older than 12 years)5–10 minutes
Buccal solution (child seizure rescue)5–10 minutes
Oral syrup (pediatric preoperative use)15–20 minutes

Because the different routes of administration reach the brain at different speeds, clinicians may start with smaller doses and gradually titrate the dose up as needed to reach (but not exceed) the desired effect.

Midazolam dosage

Sedation (in adults younger than 65 years):

  • Start with 0.5 mg IV and reassess response prior to giving additional doses.
  • Additional doses are usually given in 0.5 mg increments, the total dose rarely exceeds 5 mg.

Sedation (in adults 65 years and older or those with frailty):

  • Start with 0.5 mg IV and give additional 0.5 mg doses as needed.
  • The total dose rarely exceeds 3.5 mg.

Induction of anesthesia and ICU infusions:

  • The starting dose may be 0.01 to 0.1 mg per kg intravenously, with slow titrations as needed to achieve desired sedation while avoiding hemodynamic compromise.
  • The lower end of the range should be used when an opioid or propofol is also given.

In patients with severe liver dysfunction or those taking potent CYP3A4 inhibitors, lower starting doses and extended monitoring are advised to avoid drug accumulation and prolonged sedation.

Children and seizure rescue

  • Intranasal spray (for those weighing > 40 kg): The initial dose is 10 mg, delivered as one 5 mg spray in each nostril. A second dose is given only if cluster seizures restart after 10 minutes.
  • Buccal midazolam (weight 10–39 kg): The initial dose is 0.3 mg per kg, with a maximum of 10 mg.
  • Preoperative anxiety (six months to 12 years): The initial dose is 0.5 mg per kg via oral syrup, with a maximum of 20 mg, about 30 minutes before anesthesia.

(All amounts refer to midazolam base. Always confirm the strength printed on the vial or spray.)

Is it possible to overdose on midazolam?

It is possible to overdose on midazolam. The likelihood of an overdose may be higher when midazolam is used with other medications or substances that have depressant effects. Additive depressant effects can slow breathing, lower blood pressure, and cause a loss of consciousness. First-line care in response to midazolam overdose is to ensure the airway is open and provide high-flow oxygen. Paramedics may use a bag-mask or place a breathing tube if necessary.

Flumazenil, an antidote given IV, can counteract the effects of midazolam after an acute overdose; in long-term users, it may provoke seizures, so emergency clinicians weigh the risks before giving it.

Withdrawal and tapering

Using midazolam every day for a week or more can lead to physical dependence. Clinicians often convert the day’s total dose to an equivalent amount of diazepam, then reduce that combined amount by five to ten percent every one to two weeks. People with epilepsy, severe anxiety, or very high doses may need even smaller steps and inpatient monitoring.

Hazardous combinations

Midazolam is broken down by a liver enzyme called CYP3A4. Drugs that affect this enzyme can significantly increase midazolam levels, leading to unexpected sedation or overdose. The combinations below are especially hazardous and should be avoided or closely monitored.

  • Opioids or alcohol, like midazolam, these are also CNS depressants, which cumulatively slow breathing much more when any of them are used alone.
  • Gabapentin or diphenhydramine deepen sedation and can hide early signs of overdose.
  • Strong CYP3A4 inhibitors, which slow drug metabolism in the liver (such as ketoconazole and erythromycin), can significantly increase midazolam levels; therefore, prolonged monitoring is required.
  • CYP3A4 inducers, which speed up drug metabolism in the liver (such as phenytoin or St. John’s wort), may lower midazolam levels, increasing the chance of under-sedation and difficult dosing.

Awareness of these interactions helps ensure safer dosing.

Midazolam in polysubstance use

Some people use Versed® alongside high-dose opioids or with alcohol to deepen sedation, intensify euphoria, or trigger amnesia. Naloxone reverses opioid effects but cannot fix breathing difficulties caused by midazolam. This makes overdoses involving both drugs harder to treat. A slow benzodiazepine taper, paired with opioid agonist therapy, significantly lowers the risk of fatal relapse.

Getting help for midazolam misuse

Stopping midazolam after regular or high-dose use should never be done abruptly. Withdrawal can be dangerous, especially when other depressants are involved, and it requires a structured plan. The approaches below are clinically supported and reduce the risk of complications or relapse:

Early referral to an addiction-informed clinician roughly halves emergency readmissions within six months. If you or a loved one is struggling with midazolam misuse, or if you’re worried about your midazolam use, help is available confidentially and without judgment. See our directory for help.

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Resources:

  1. Accord Healthcare Ltd. (2024). Midazolam 2 mg/ml solution for injection or infusion: Summary of product characteristics. Electronic Medicines Compendium.
  2. Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., … Jaeschke, R, American College of Critical Care Medicine (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine, 41(1), 263–306. 
  3. Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., Barsan, W., & NETT Investigators (2012). Intramuscular versus intravenous therapy for prehospital status epilepticus. The New England journal of medicine366(7), 591–600. 
  4. Wheless J. W. (2021). A critical evaluation of midazolam nasal spray for the treatment of patients with seizure clusters. Expert review of neurotherapeutics21(11), 1195–1205. 
  5. Flood, C., Matthew, L., Marsh, R., Patel, B., Mansaray, M., & Lamont, T. (2015). Reducing risk of overdose with midazolam injection in adults: an evaluation of change in clinical practice to improve patient safety in England. Journal of evaluation in clinical practice21(1), 57–66. 

Activity History - Last updated: 29 May 2025, Published date:


Reviewer

Dr. Jennie Stanford

MD, FAAFP, DipABOM

Jennie Stanford, MD, FAAFP, DipABOM is a dual board-certified physician in both family medicine and obesity medicine. She has a wide range of clinical experiences, ranging from years of traditional clinic practice to hospitalist care to performing peer quality review to ensure optimal patient care.

Activity History - Medically Reviewed on 28 May 2025 and last checked on 29 May 2025

Medically reviewed by
Dr. Jennie Stanford

Dr. Jennie Stanford

MD, FAAFP, DipABOM

Reviewer

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