lorazepam ATIVAN
Class: Benzodiazepine/3-HydroxyFDA Indications: Anxiety Disorders, Status Epilepticus (IM Only), Preanesthetic (IM Only)
Off-Label Use: Alcohol Withdrawal, Preanesthetic, Insomnia, Catatonia, Delirium, Acute Dystonia, Agitation In The ICU Patient, Agitation/aggression
Prescribing
FDA Schedule IVForms: 0.5, 1, 2mg tablet; 2 mg/mL, 4 mg/mL IM
Dose Range: 0.5-10 mg/day
Starting: 2-3 mg daily in 2 to 3 divided doses
Stopping: Taper 0.5 mg q3 days, slower (0.25 mg per week) for more difficult cases
Precautions
Contraindications: Sleep apnea, acute narrow-angle glaucomaSerious Side Effects: Overdose can result in hypotension, respiratory depression, and coma
Side Effects: sedation/somnolence, dizziness, confusion, disequilibrium, ataxia, lightheadedness, weakness/asthenia, decreased libido, dysarthria, constipation, increased appetite, weight gain
Pharmacokinetics
t½: 15 (8-24)° TMAX: 1-4°Absorption Rate: Medium
Lipid Solubility: Low-moderate
Substrate of: Conjugation
Inhibits: ∅ ; Induces: ∅
Active Metabolites: ∅
DDIs
- - CNS depression with combined use of opioids
- - VPA ↑'s plasma concentration and reduces clearance via impairing hepatic glucuronidation
Misc
- - dosage should be ↓ by 50% with concurrent use of valproate or probenecid
- - the only benzodiazepine with predictable intramuscular absorption
- - one of few benzodiazepines available as po liquid
Special Populations
Category D—↑ risk of oral cleft by 0.01%, use just before delivery associated with floppy infant syndrome, 3rd trimester use can cause withdrawal in newborns
Short t½ benzodiazepines such as lorazepam (RID 2.9%) are excreted into breast milk in miniscule amounts and ∴ preferred over longer-acting agents; ∅ AE's have been reported
Per Beers Criteria, should be avoided in patients ≥65 years. If used, start low 1-2 mg in divided doses.
2019 BEE℞S Recommendation: Avoid. Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long- acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. May be appropriate for seizure disorders, RBD, benzodiazepine withdrawal, EtOH withdrawal, severe GAD, and periprocedural anesthesia.
No dosage adjustment necessary
No dose adjustment necessary with mild-moderate liver dz; use with caution if severe insufficiency