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# Lorazepam
## Overview
Lorazepam is a benzodiazepine with anxiolytic, sedative, hypnotic, and anticonvulsant properties. It is metabolized by glucuronidation and has an intermediate half-life.
## Primary Indications
* Anxiety disorders
* Insomnia (short-term treatment)
* Status epilepticus (adjunctive or first-line therapy)
* Sedation (preoperative, ICU)
* Management of alcohol withdrawal symptoms
## Adult Dosing
* **Anxiety:** 0.5 mg to 2 mg orally or IM every 6 to 8 hours as needed. Maximum daily dose generally 10 mg.
* **Insomnia:** 2 mg to 4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg IV. May repeat 4 mg after 5 to 10 minutes if seizure persists. Maximum dose 8 mg. Intramuscular administration may be used if IV access is not available, typically 100 mcg/kg up to a maximum of 4 mg per dose.
* **Preoperative Sedation:** 2 mg to 4 mg IM 2 hours before surgery.
* **ICU Sedation:** Initial dose of 0.02 mg/kg to 0.1 mg/kg (up to 4 mg) IM or IV, followed by a continuous infusion of 0.03 mg/kg/hour to 0.1 mg/kg/hour (titrated to effect).
## Pediatric Dosing
Dosing in pediatric patients is highly variable and should be individualized based on age, weight, and clinical condition. **Consult specific pediatric guidelines or protocols.**
* **Status Epilepticus:** 0.05 mg/kg to 0.1 mg/kg IV, maximum 4 mg per dose. May repeat once after 5 to 10 minutes. Maximum total dose generally 8 mg. IM dosing is also an option.
* **Sedation:** Dosing varies widely.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; reduced doses may be necessary.
* **Renal Impairment:** Dose adjustments are generally not required, but use with caution.
* **Elderly:** Start with lower doses (e.g., 0.5 mg twice daily) and titrate slowly due to increased sensitivity and risk of CNS depression.
## Contraindications
* Known hypersensitivity to lorazepam or other benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency.
* Severe hepatic insufficiency.
* Sleep apnea.
## Adverse Effects
Common adverse effects include drowsiness, dizziness, weakness, and ataxia. Less common but serious effects include respiratory depression, paradoxical reactions (agitation, confusion), anterograde amnesia, and dependence with prolonged use.
## Key Drug Interactions
* **CNS Depressants (opioids, alcohol, other sedatives, antihistamines):** Increased risk of profound sedation, respiratory depression, coma, and death. Use concurrently only if no alternative exists, with the lowest effective doses and shortest duration, and monitor closely.
* **Theophylline/Aminophylline:** May antagonize the sedative effects of lorazepam.
* **Valproic acid:** May decrease lorazepam clearance, potentially increasing plasma concentrations.
## Monitoring
* **For anxiety/insomnia:** Monitor for therapeutic effect, sedation, dizziness, and signs of dependence.
* **For status epilepticus:** Monitor seizure activity, vital signs (respiratory rate, blood pressure, heart rate), and level of consciousness.
* **For ICU sedation:** Continuous monitoring of sedation level (e.g., RASS score), vital signs, and signs of delirium.
* **Withdrawal symptoms:** Monitor for signs and symptoms of benzodiazepine withdrawal upon discontinuation.
## Clinical Pearls
* Lorazepam is often the benzodiazepine of choice for status epilepticus due to its relatively rapid onset and intermediate duration of action.
* Intramuscular lorazepam is well-absorbed, unlike some other benzodiazepines.
* Avoid abrupt discontinuation, especially after prolonged use, due to risk of withdrawal symptoms (insomnia, anxiety, tremors, dysphoria, seizures). Taper gradually.
* Use in pregnancy is generally discouraged due to potential risks to the fetus, particularly in the third trimester (e.g., floppy infant syndrome, withdrawal symptoms).
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**Disclaimer:** This information is intended for clinical use and does not replace professional judgment. Always verify current prescribing information with the manufacturer's product monograph or other reliable resources before making clinical decisions.
