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# Lorazepam
## Overview
Lorazepam is a benzodiazepine with anxiolytic, sedative, hypnotic, and anticonvulsant properties.
## Primary Indications
* Anxiety disorders
* Insomnia characterized by difficulty with sleep onset
* Seizure management (status epilepticus)
* Preoperative sedation
## Adult Dosing
* **Anxiety:** Typically 0.5 mg to 2 mg orally 2 to 3 times daily. Maximum daily dose generally 10 mg.
* **Insomnia:** 2 mg to 4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg intravenously (IV) or intramuscularly (IM). May repeat in 5 to 10 minutes if needed. Maximum initial dose 8 mg.
## Pediatric Dosing
Dosing in pediatric patients is highly variable and should be based on specific indication, weight, and clinical response. Consult specialized pediatric resources.
* **Preoperative Sedation:** Age ≥ 12 years: 2 mg orally 1 to 2 hours before surgery.
* **Status Epilepticus:** Age ≥ 18 years: 4 mg IV or IM. May repeat in 5 to 10 minutes if needed. Maximum initial dose 8 mg. (Dosing for younger pediatric patients is less established and requires careful consideration).
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary.
* **Renal Impairment:** Use with caution. Dose reduction may be necessary for severe impairment.
* **Elderly:** Start with lower doses (e.g., 0.5 mg orally twice daily) and titrate cautiously due to increased sensitivity and risk of adverse effects.
## Contraindications
* Known hypersensitivity to benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency.
* Severe hepatic insufficiency.
* Myasthenia gravis.
* Sleep apnea syndrome.
## Adverse Effects
* **Common:** Sedation, drowsiness, dizziness, weakness, ataxia.
* **Less Common:** Confusion, depression, memory impairment, paradoxical excitation, hypotension, respiratory depression (especially with IV administration or in combination with other CNS depressants).
## Key Drug Interactions
* **CNS Depressants (e.g., alcohol, opioids, other benzodiazepines, barbiturates, antihistamines):** Additive CNS depression, potentially leading to profound sedation, respiratory depression, coma, and death. Avoid concurrent use or use with extreme caution and reduced doses.
* **CYP3A4 Inhibitors/Inducers:** Lorazepam is primarily metabolized by glucuronidation, not CYP enzymes, so interactions via this pathway are less significant compared to other benzodiazepines.
## Monitoring
* Level of sedation and respiratory rate, especially with IV administration.
* Cognitive function and risk of falls, particularly in elderly patients.
* Signs of dependence or withdrawal if used long-term.
## Clinical Pearls
* Intravenous lorazepam is a first-line agent for status epilepticus.
* Intramuscular administration is effective and may be preferred when IV access is difficult.
* Due to its slower onset and longer duration of action, lorazepam is generally not the preferred agent for initial insomnia treatment compared to agents with shorter half-lives, though it is effective.
* Abrupt discontinuation after prolonged use can lead to withdrawal symptoms, including anxiety, insomnia, tremors, and seizures. Tapering of the dose is recommended.
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*Disclaimer: This information is intended for healthcare professionals. Always verify current prescribing information and consult relevant clinical guidelines and drug compendia before making therapeutic decisions.*
