lorazepam (Rx)

Brand and Other Names:Ativan
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

tablet: Schedule IV

  • 0.5mg
  • 1mg
  • 2mg

oral concentrate: Schedule IV

  • 2mg/mL

injectable solution: Schedule IV

  • 2mg/mL
  • 4mg/mL
more...

Anxiety Disorders

Initial: 2-3 mg PO q8-12hr PRN; not to exceed 10 mg/day

Maintenance: 2-6 mg/day PO divided q8-12hr

Short-Term Treatment of Insomnia

2-4 mg PO qHS

Preoperative Sedation, Anxiety Relief, & Anterograde Amnesia

0.05 mg/kg IM for 1 dose; 2 hours before surgery; not to exceed 4 mg (2 mg/dose in elderly), OR 

0.044 mg/kg IV for 1 dose; 15-20 minutes before surgery; not to exceed 4 mg (2 mg/dose in elderly)

Status Epilepticus

Usual 4 mg/dose slow IV at 2 mg/min

If seizure persists after 5-10 min, administer 4 mg IV again

Anxiolytic/Sedation in ICU (Off-label)

Intubated and mechanically ventilated patients

  • 0.02-0.04 mg/kg loading dose IV
  • 0.02-0.06 mg/kg intermittent IV q2-6hr PRN, OR 
  • 0.01-0.1 mg/kg/hr continuous IV; not to exceed 10 mg/hr

Chemotherapy-Induced Nausea/Vomiting (Off-label)

0.5-2 mg PO/IV q6hr; PRN thereafter

Chronic Insomnia (Off-label)

2-4 mg PO qHS

Dosing Considerations

IV: Monitor respirations q5-15min and before each repeated IV dose

Dosing Modifications

Renal impairment

  • PO: Dose adjustment not necessary
  • IV/IM: Use with caution in mild-to-moderate impairment; not recommended in severe impairment or renal failure
  • IV/IM (prolonged periods or high doses): Monitor; risk of propylene glycol toxicity

Hepatic impairment

  • PO: No dose adjustment recommended in mild-to-moderate impairment; use with caution (may require lower dose) in severe impairment
  • IV/IM: Use with caution in mild-to-moderate impairment; not recomended in severe impairment of hepatic failure

Dosage Forms & Strengths

tablet: Schedule IV

  • 0.5mg
  • 1mg
  • 2mg

oral concentrate: Schedule IV

  • 2mg/mL

injectable solution: Schedule IV

  • 2mg/mL
  • 4mg/mL
more...

Status Epilepticus (Off-label)

Infants and children: 0.05-0.1 mg/kg IV over 2-5 minutes; not to exceed 4 mg/dose; may repeat q10-15min PRN 

Alternatively, 0.1 mg/kg at slow IV rate not to exceed rate of 2 mg/min; not to exceed dose of 4 mg

Adolescents: 4 mg slow IV; if seizure persists after 10-15 minutes, administer 4 mg IV again

Anxiolytic/Sedation/Agitation (Off-label)

Children: 0.05 mg/kg/dose PO q4-8hr; not to exceed 2 mg/dose 

Chemotherapy-Induced Nausea/Vomiting (Off-label)

Children >2 years: 0.025-0.05 mg/kg/dose IV q6hr PRN; not to exceed 2 mg/dose 

Dosing Considerations

IV: Monitor respirations q5-15min and before each repeated IV dose

Preferred agent in elderly because short-acting and has inactive metabolite

Anxiety disorders

Lower initial dose recommended; 1-2 mg PO divided q8-12hr

Insomnia

Lower initial dose recommended; 0.5-1 mg PO qHS, increase PRN

To avoid oversedation, initial daily dose should not exceed 2 mg

Dosing considerations

When higher dose indicated, increase evening dose before daytime doses

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Interactions

Interaction Checker

and lorazepam

No Results

     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            Frequency Not Defined

            Sedation

            Dizziness

            Unsteadiness

            Weakness

            Fatigue

            Drowsiness

            Amnesia

            Confusion

            Disorientation

            Depression

            Suicidal ideation/attempt

            Vertigo

            Ataxia

            Sleep apnea

            Asthenia

            Extrapyramidal symptoms

            Respiratory depression

            Tremor

            Convulsions/seizures

            Visual disturbances

            Dysarthria

            Hypotension

            Blood dyscrasias

            Change in libido

            Impotence

            Jaundice

            Increased bilirubin

            Increased liver transaminases

            Increase in ALP

            Hypersensitivity reactions

            Nausea

            Constipation

            Change in appetite

            Paradoxical reactions (anxiety, excitation, agitation, hostility, aggression, rage)

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            Warnings

            Black Box Warnings

            Risks From Concomitant Use With Opioids

            • Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death
            • Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate
            • Limit dosages and durations to the minimum required
            • Follow patients for signs and symptoms of respiratory depression and sedation

            Contraindications

            Documented hypersensitivity

            Acute narrow angle glaucoma

            Intra-arterial administration

            Severe respiratory depression

            Sleep apnea

            Use of injectable dosage form in premature infants (contains benzyl alcohol)

            Cautions

            Concomitant use of benzodiazepines, including lorazepam, and opioids may result in profound sedation, respiratory depression, coma, and death (see BBW)

            Advise both patients and caregivers about the risks of respiratory depression and sedation when lorazepam is used with opioids; advise patients not to drive or operate heavy machinery until the effects of concomitant use with the opioid have been determined

            Use of benzodiazepines, including lorazepam, both used alone and in combination with other CNS depressants, may lead to potentially fatal respiratory depression

            Not recommended for use in patients with primary depressive disorder or psychosis

            Injection contains benzyl alcohol associated with potentially fatal "gasping syndrome" in neonates and an increased incidence of kernicterus, particularly in small preterm infants; if patient requires more than recommended dosages or other medications containing this preservative, practitioner must consider daily metabolic load of benzyl alcohol from combined sources

            Prolonged use may lead to physical and psychological dependence especially in patients with history of alcohol or drug abuse; risk of dependence is decreased with short-term treatment (eg, 2-4 weeks); evaluate need for continued treatment prior to extending therapy duration

            Use caution in patients with history of suicide attempt or drug abuse

            Do not withdraw abruptly after prolonged use; terminate dosage gradually

            Use caution in patients with impaired gag reflex

            May cause CNS depression, impairing physical and mental abilities; caution patients to not operate dangerous machinery or motor vehicles

            Anterograde amnesia reported with use

            Use caution in patients with respiratory disease, including COPD or sleep apnea

            Hyperactive or aggressive behavior and other paradoxical reactions reported with use

            Caution patients that tolerance for alcohol and other CNS depressants will be diminished

            General anesthetics and sedation drugs in young children and pregnant women

            • Brain development
              • Published animal studies demonstrate that administration of anesthetic and sedation drugs that block NMDA receptors and/or potentiate GABA activity increase neuronal apoptosis in developing brain and result in long-term cognitive deficits when used for longer than 3 hours; repeated exposure may also result in negative effects on fetal or young children’s brain development
              • Caution with use during surgeries or procedures in children younger than 3 yr or in pregnant women during their third trimester
              • Assess the risk:benefit ratio in these populations, especially for prolonged procedures (ie, >3 hr) or multiple procedures
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            Pregnancy & Lactation

            Pregnancy category: D

            Lactation: Excreted in human breast milk; not recommended

            Risk of serious adverse effects, including CNS and respiratory depression, exist

            Minor tranquilizers should be avoided in first trimester of pregnancy, due to increased risk of congenital malformations

            Maternal use shortly before delivery is associated with floppy infant syndrome (good and consistent evidence)

            Prenatal benzodiazepine exposure slightly increased oral cleft risk (limited or inconsistent evidence)

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Sedative hypnotic with short onset of effects and relatively long half-life; by increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, lorazepam may depress all levels of the CNS, including limbic and reticular formation

            Absorption

            Bioavailability: 90%

            Onset: 1-3 min (IV in sedation); 15-30 min (IM in hypnosis)

            Duration: Up to 8 hr

            Peak plasma time: 2 hr (PO); <3 hr (IM)

            Peak plasma concentration: 20 ng/mL

            Distribution

            Protein bound: 85-93%

            Vd: 1.9 L/kg (adolescents); 1.3 L/kg (adults); 0.78 L/kg (neonates)

            Metabolism

            Metabolites: Inactive

            Undergoes glucuronic acid conjugation

            Elimination

            Half-life: 18 hr (children 2-12 years); 42 hr (neonates); 28 hr (adolescents); 18 hr (end stage renal disease); 14 hr (adults)

            Excretion: Urine (88% mainly as inactive metabolites); feces (7%)

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            Administration

            IV Incompatibilities

            Additive: Buprenorphine, dexamethasone sodium phosphate with diphenhydramine and metoclopramide

            Syringe: Sufentanil

            Y-site: Aldesleukin, aztreonam, floxacillin, foscarnet, idarubicin, imipenem/cilastatin, omeprazole, ondansetron, sargramostim, sufentanil

            IV Preparation

            Parenteral admixture stable for 24 hr at room temp (25°C)

            Usually given IVP

            Standard IVP dilution: dilute immediately before use with equal amount of NS or SWI

            Usual dilution for continuous infusion: 1 mg in 100 mL D5W

            Discard if discoloration or precipitate

            IV/IM Administration

            IM administration

            • Administer deep into muscle mass

            IV administration

            • Prior to use, dilute injection solution with an equal amount of compatible diluent (D5W, NS, SWFI)
            • Administer IV injection slowly, directly into a vein or into tubing of a free-flowing, compatible IV infusion (eg, NS, D5W), at no more than 2 mg/min
            • Validate patent venous catheter with repeated aspiration during infusion to visualize venous blood return
            • Inadvertent intra-arterial injection may produce arteriospasm resulting in gangrene, potentially requiring amputation
            • Rapid IV infusion may result in apnea, bradycardia, hypotension, cardiac arrest
            • Continuous infusion solutions should have an in-line filter and should be checked frequently for possible precipitation
            • Emergency resuscitative equipment should be available when administering IV

            Storage

            IV/IM injection: Refrigerate intact vials at 2-8°C (36-46°F) and protect contents from light

            Tablets: Keep tightly closed; store at 25°C (77°F)

            Oral concentrate: Store at cold temperature; refrigerate at 2-8°C (36-46°F); discard open bottle after 90 days

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

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            • View the formulary and any restrictions for each plan.
            • Manage and view all your plans together – even plans in different states.
            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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