Lorazepam (Ativan) Overview
Lorazepam (Ativan) is a widely-used benzodiazepine known for its potent anxiolytic, sedative-hypnotic, and muscle relaxant properties. It is most effective due to its action on the central nervous system through the neurotransmitter GABA.
Generic Name:
Lorazepam (lor-a´ze-pam)
Brand Name:
Ativan
Classifications:
- Central nervous system agent
- Anxiolytic
- Sedative-hypnotic
- Benzodiazepine
Pregnancy Category:
D
Availability:
- 0.5 mg, 1 mg, 2 mg tablets
- 2 mg/mL oral solution
- 2 mg/mL, 4 mg/mL injection
Actions:
Most potent of the available benzodiazepines. Effects (anxiolytic, sedative, hypnotic, and skeletal muscle relaxant) are mediated by the inhibitory neurotransmitter GABA. Action sites: thalamic, hypothalamic, and limbic levels of CNS.
Therapeutic Effects:
An antianxiety agent that also causes mild suppression of REM sleep, while increasing total sleep time.
Uses:
- Management of anxiety disorders
- Short-term relief of symptoms of anxiety
- Preanesthetic medication to produce sedation and reduce anxiety and recall of events related to surgery
- Management of status epilepticus
Contraindications:
- Known sensitivity to benzodiazepines
- Acute narrow-angle glaucoma
- Primary depressive disorders or psychosis
- Children under 12 years (PO preparation)
- Coma, shock, acute alcohol intoxication
- Pregnancy (category D), and lactation
Cautious Use:
- Renal or hepatic impairment
- Organic brain syndrome
- Myasthenia gravis
- Narrow-angle glaucoma
- Suicidal tendency
- GI disorders
- Older adult and debilitated patients
- Limited pulmonary reserve
Route & Dosage:
Antianxiety:
- Adults: PO 2–6 mg/d in divided doses (max: 10 mg/d)
- Geriatric: PO 0.5–1 mg/d (max: 2 mg/d)
- Children: PO/IV 0.05 mg/kg q4–8h (max: 2 mg/dose)
Insomnia:
- Adults: PO 2–4 mg at bedtime
- Geriatric: PO 0.5–1 mg h.s.
Premedication:
- Adults: IM 2–4 mg (0.05 mg/kg) at least 2 h before surgery; IV 0.044 mg/kg up to 2 mg 15–20 min before surgery
- Children: PO/IV/IM 0.05 mg/kg (range: 0.02–0.09 mg/kg)
Status Epilepticus:
- Adults: IV 4 mg injected slowly at 2 mg/min, may repeat dose once if inadequate response after 10 min
- Children: IV 0.1 mg/kg slow IV over 2–5 min (max: 4 mg/dose), may repeat with 0.05 mg in 10–15 min if needed
- Neonate: IV 0.05 mg/kg over 2–5 min, may repeat in 10–15 min
Administration:
Oral:
- Increase the evening dose when a higher oral dosage is required, before increasing daytime doses.
Intramuscular:
- Injected undiluted, deep into a large muscle mass.
Intravenous:
- IV administration to neonates, infants, children: Verify the correct IV concentration and rate of infusion with the physician.
- Patients >50 years old may have more profound and prolonged sedation with IV lorazepam (usual max: initial dose of 2 mg).
Preparation (Direct):
- Prepare lorazepam immediately before use. Dilute with an equal volume of sterile water, D5W, or NS.
- Administration (Direct): Inject directly into the vein or into IV infusion tubing at a rate not to exceed 2 mg/min and with repeated aspiration to confirm IV entry. Take extreme precautions to prevent intraarterial injection and perivascular extravasation.
- Incompatibilities (Y-site): Idarubicin, Omeprazole, Ondansetron, Sargramostim, Sufentanil, TPN with Albumin.
Storage:
- Keep parenteral preparation in the refrigerator; do not freeze.
- Do not use a discolored solution or one with a precipitate.
Adverse Effects:
- Body Whole: Usually disappears with continued medication or with reduced dosage.
- CNS: Anterograde amnesia, drowsiness, sedation, dizziness, weakness, unsteadiness, disorientation, depression, sleep disturbance, restlessness, confusion, hallucinations.
- CV: Hypertension or hypotension.
- Spec Senses: Blurred vision, diplopia; depressed hearing.
- GI: Nausea, vomiting, abdominal discomfort, anorexia.
Nursing Implications:
Assessment & Drug Effects:
- Have equipment for maintaining a patent airway immediately available before starting IV administration.
- IM or IV lorazepam injection of 2–4 mg is usually followed by a depth of drowsiness or sleepiness that permits the patient to respond to simple instructions whether the patient appears to be asleep or awake.
- Supervise ambulation of older adult patients for at least 8 hours after lorazepam injection to prevent falling and injury.
- Lab tests: Assess CBC and liver function tests periodically for patients on long-term therapy.
- Supervise patient who exhibits depression with anxiety closely; the possibility of suicide exists, particularly when there is apparent improvement in mood.
Patient & Family Education:
- Do not drive or engage in other hazardous activities for at least 24–48 hours after receiving an IM injection of lorazepam.
- Do not drink large volumes of coffee. Anxiolytic effects of lorazepam can significantly be altered by caffeine.
- Do not consume alcoholic beverages for at least 24–48 hours after an injection and avoid when taking an oral regimen.
- Notify the physician if daytime psychomotor function is impaired; a change in regimen or drug may be needed.
- Terminate the regimen gradually over a period of several days. Do not stop long-term therapy abruptly; withdrawal may be induced by feelings of panic, tonic-clonic seizures, tremors, abdominal and muscle cramps, sweating, and vomiting.
- Do not self-medicate with OTC drugs; seek physician guidance.
- Discuss discontinuation of the drug with the physician if you wish to become pregnant.
- Do not breastfeed while taking this drug.
References
- Wong, E. K., Dunn, T. E., Beaver, B. P., Neronha, Z. J., & Chuu, A. (2023). Current Evidence Surrounding the Use of Lorazepam in the Critically Ill Patient. Current Emergency and Hospital Medicine Reports, 11, 26-34. Retrieved from https://link.springer.com/article/10.1007/s40138-023-00260-9
- Grgic, J., Grgic, I., Del Coso, J., Schoenfeld, B. J., & Pedisic, Z. (2021). Effects of Lorazepam Supplementation on Exercise Performance: An Umbrella Review. Journal of the International Society of Sports Nutrition, 18, 71. Retrieved from https://jissn.biomedcentral.com/articles/10.1186/s12970-021-00469-7
- SciTechDaily. (2023). Lorazepam Saves the World: New Additive in Medication Mix Could Revolutionize Anxiety Treatment. Retrieved from https://scitechdaily.com/lorazepam-saves-the-world-new-additive-in-medication-mix-could-revolutionize-anxiety-treatment/