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# Ativan (Lorazepam)
## Overview
Lorazepam is a high-potency benzodiazepine with an intermediate duration of action. It acts as a positive allosteric modulator of the GABA-A receptor, producing anxiolytic, sedative, anticonvulsant, and muscle relaxant effects.
## Primary Indications
* Anxiety disorders (short-term management)
* Status epilepticus
* Preoperative sedation
* Insomnia
* Acute alcohol withdrawal
## Adult Dosing
* **Anxiety:** 1–3 mg orally per day in divided doses (Max: 10 mg/day).
* **Insomnia:** 2–4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg IV/IM (may repeat once after 10–15 minutes).
* **Preoperative Sedation:** 0.05 mg/kg (up to 4 mg max) IM 2 hours before procedure, or 0.044 mg/kg (up to 2 mg max) IV 15–20 minutes before procedure.
## Pediatric Dosing
* **Status Epilepticus (Off-label/Protocol-dependent):** 0.05–0.1 mg/kg IV/IM (Max: 4 mg per dose). Repeat once if seizures persist after 10–15 minutes.
* **Preoperative Sedation:** 0.05 mg/kg (Max: 2 mg) IM/IV.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; lower initial doses are required as lorazepam undergoes glucuronidation, which is generally preserved longer than oxidative metabolism but can still be impaired in severe cirrhosis.
* **Renal Impairment:** No dose adjustment typically required, but use with caution due to accumulation of inactive glucuronide metabolites.
* **Geriatric/Debilitated Patients:** Start at the lowest possible dose (e.g., 0.5 mg) due to increased sensitivity and risk of falls/confusion.
## Contraindications
* Hypersensitivity to benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency.
* Sleep apnea syndrome (relative contraindication).
## Adverse Effects
* **Common:** Sedation, dizziness, ataxia, fatigue, anterograde amnesia.
* **Serious:** Respiratory depression (especially with opioids), paradoxical excitation, hypotension, dependence/withdrawal symptoms upon cessation.
## Key Drug Interactions
* **Opioids:** Profound risk of respiratory depression, coma, and death; avoid concurrent use if possible (Black Box Warning).
* **CNS Depressants:** Alcohol, barbiturates, and other sedatives have additive effects.
* **Valproic Acid:** May inhibit lorazepam glucuronidation, increasing serum concentrations.
## Monitoring
* **Acute Settings:** Continuous pulse oximetry, blood pressure, and respiratory rate.
* **General:** Assess for excessive sedation, cognitive impairment, and signs of misuse or dependence.
## Clinical Pearls
* **Status Epilepticus:** Lorazepam is the first-line agent for status epilepticus due to its longer duration of action in the CNS compared to diazepam.
* **Withdrawal:** Abrupt discontinuation after chronic use can cause seizures; taper dose gradually based on duration of therapy.
* **IM Absorption:** Unlike diazepam, lorazepam is reliably absorbed following intramuscular injection.
* **Injection:** Always dilute the injection concentrate with an equal volume of compatible diluent (sterile water or NS).
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**Disclaimer:** This information is for educational purposes for healthcare professionals. Clinical practice varies by institution; always verify current prescribing information, local medical protocols, and the patient's specific clinical status before administration.
