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# Lorazepam
## Overview
Lorazepam is a benzodiazepine with sedative, hypnotic, anxiolytic, and anticonvulsant properties.
## Primary Indications
* Anxiety disorders
* Insomnia due to anxiety
* Status epilepticus
* Sedation (pre-operative, ICU)
* Management of alcohol withdrawal symptoms
## Adult Dosing
* **Anxiety:** 0.5-2 mg orally 2-3 times daily. Maximum: 10 mg/day.
* **Insomnia:** 2-4 mg orally at bedtime.
* **Status Epilepticus:** 2-4 mg IV/IM initially. May repeat 2-4 mg every 5-10 minutes up to a maximum of 10 mg.
* **Pre-operative Sedation:** 2-4 mg IM or IV 2 hours before surgery.
* **ICU Sedation:** 0.02-0.1 mg/kg IV per dose, may be repeated every 15-30 minutes. Or, continuous infusion: 0.05-0.1 mg/kg/hour. *Specific infusion rates depend on patient response and institution protocol.*
* **Alcohol Withdrawal:** 1-4 mg orally or IV/IM every 4-6 hours as needed. *Titrate based on symptoms and institute protocol.*
## Pediatric Dosing
* **Status Epilepticus:** 0.1 mg/kg IV/IM per dose, maximum 4 mg. Repeat every 5-10 minutes if needed. *Dosing in children is less well-established and requires careful titration and monitoring.*
* **Anxiety/Sedation:** No established pediatric dose for general anxiety or routine sedation. Use is generally discouraged in favor of other agents due to potential for paradoxical reactions and respiratory depression. If used, start with very low doses (e.g., 0.02 mg/kg orally or IV/IM) and titrate carefully.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution, may require dose reduction.
* **Renal Impairment:** No specific dose adjustment, but monitor closely for increased sensitivity.
* **Elderly:** Initiate at the lower end of the adult dose range (e.g., 0.5 mg orally 1-2 times daily for anxiety) and titrate slowly. Increased sensitivity to CNS depressant effects.
## Contraindications
* Known hypersensitivity to lorazepam or other benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency.
* Severe hepatic insufficiency (e.g., hepatic coma).
## Adverse Effects
Common: Drowsiness, dizziness, sedation, ataxia, weakness, confusion.
Less Common: Paradoxical excitement, depression, amnesia, visual disturbances, hypotension, respiratory depression (especially with IV administration or in combination with other CNS depressants).
## Key Drug Interactions
* **CNS Depressants (opioids, alcohol, other sedatives/hypnotics):** Increased risk of profound sedation, respiratory depression, coma, and death.
* **Valproic acid:** May decrease lorazepam clearance and increase plasma concentrations. Consider dose reduction of lorazepam.
* **Probenecid:** May decrease lorazepam clearance.
* **Theophylline/Aminophylline:** May reduce lorazepam's sedative effects.
## Monitoring
* Level of sedation and CNS depression.
* Respiratory rate and oxygen saturation.
* Blood pressure.
* Signs of paradoxical reactions.
* Signs of withdrawal upon discontinuation.
## Clinical Pearls
* Lorazepam has a relatively long half-life and can accumulate with repeated dosing.
* IV administration can cause respiratory depression and hypotension; administer slowly (e.g., 2 mg/minute) and have resuscitation equipment readily available.
* Intramuscular (IM) absorption can be slower and more variable than oral or IV.
* Avoid abrupt discontinuation to prevent withdrawal symptoms. Taper dose gradually.
* Use with caution in patients with sleep apnea or other respiratory conditions.
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*This information is intended for clinical use and does not substitute for professional medical advice. Always verify current prescribing information, institutional protocols, and patient-specific factors before making therapeutic decisions.*
