Lorazepam

1. Introduction

Lorazepam is a benzodiazepine used for its anxiolytic, sedative, anticonvulsant, and muscle relaxant properties. It works by enhancing the effects of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, producing a calming effect.

2. Indications

  • Approved Indications:
    • Anxiety disorders.
    • Insomnia associated with anxiety or transient stress.
    • Preoperative sedation.
    • Status epilepticus (IV use).
  • Off-Label Uses:
    • Alcohol withdrawal syndrome.
    • Acute agitation or aggression in psychiatric conditions.

3. Dosage

  • Anxiety:
    • Adults: 1–3 mg/day in divided doses, typically 2–6 mg/day for severe anxiety.
    • Elderly: 1–2 mg/day in divided doses (start at the lower end).
  • Insomnia:
    • Adults: 1–2 mg at bedtime.
  • Preoperative Sedation:
    • Adults: 1–4 mg IM or IV, 30–90 minutes before surgery.
  • Status Epilepticus (IV use):
    • Adults: 4 mg IV at a rate of 2 mg/min. May repeat after 10–15 minutes if seizures persist.
  • Paediatrics (Status Epilepticus):
    • 0.05–0.1 mg/kg IV every 10–15 minutes, maximum total dose of 4 mg.

4. Administration

  • Oral: Take tablets with or without food, usually at the same time daily.
  • IV/IM: Administered under medical supervision, ensuring proper dosing and monitoring.

5. Forms Available

  • Tablets: 0.5 mg, 1 mg, 2 mg.
  • Oral solution: 2 mg/mL.
  • Injection: 2 mg/mL, 4 mg/mL.

6. Side Effects

6.1. Common Side Effects

  • Drowsiness.
  • Dizziness.
  • Fatigue.
  • Weakness.

6.2. Less Common Side Effects

  • Confusion.
  • Blurred vision.
  • Nausea.

6.3. Rare but Serious Side Effects

  • Respiratory depression (especially with IV use or in high doses).
  • Dependence or withdrawal symptoms with long-term use.
  • Paradoxical reactions (e.g., agitation, irritability).

7. Warnings

  • Dependence and Withdrawal: Prolonged use can lead to physical and psychological dependence. Withdrawal symptoms may include anxiety, tremors, seizures, and insomnia.
  • Respiratory Depression: Risk increases when combined with alcohol or other CNS depressants.
  • Elderly Patients: Increased risk of sedation, falls, and cognitive impairment.

8. Precautions

  • Avoid abrupt discontinuation to prevent withdrawal symptoms. Gradually taper the dose under medical supervision.
  • Use cautiously in patients with:
    • Respiratory conditions (e.g., COPD, sleep apnoea).
    • Severe liver or kidney impairment.
    • History of substance abuse.

9. Interactions

  • Drug-Drug Interactions:
    • Alcohol and CNS depressants (e.g., opioids): Increased risk of respiratory depression and sedation.
    • Valproate: Increases lorazepam levels, requiring dose adjustments.
    • CYP3A4 inhibitors (e.g., ketoconazole): May increase lorazepam levels.
  • Drug-Food Interactions:
    • Avoid alcohol, as it enhances sedative effects.

10. Monitoring Parameters

  • Symptom relief (e.g., reduced anxiety or seizure control).
  • Signs of sedation or respiratory depression.
  • Dependence or misuse in long-term users.

11. Use in Children

  • Approved for short-term use in conditions like status epilepticus. Use cautiously and adjust doses based on weight.

12. Use in Pregnancy

  • Category D: May cause foetal harm (e.g., congenital malformations, neonatal withdrawal). Avoid use during pregnancy unless necessary.

13. Use in Elderly

  • Use cautiously at the lowest effective dose to reduce the risk of sedation, falls, and cognitive impairment.

14. Use in Kidney Disease

  • No specific dose adjustments are needed in mild to moderate renal impairment. Use cautiously in severe kidney disease.

15. Use in Liver Disease

  • Use cautiously in patients with hepatic impairment, as lorazepam is metabolised in the liver. Dose adjustments may be necessary.

16. Patient Counselling Points

  • Take lorazepam exactly as prescribed. Do not increase the dose or use it more frequently than recommended.
  • Avoid alcohol while using lorazepam, as it may increase sedation and respiratory depression.
  • Inform your doctor if you experience worsening symptoms, unusual mood changes, or excessive drowsiness.
  • Do not stop lorazepam suddenly if you have been taking it for a long time; consult your doctor for a tapering schedule.
  • Store lorazepam in a safe place to prevent misuse, especially by others in the household.

17. Table of Brand Names, Manufacturers, and Prices

Brand NameManufacturerPrice (USD)
AtivanPfizer$20–40 (30 tablets, 1 mg)
Generic LorazepamVarious manufacturers$10–30 (30 tablets, 1 mg)

18. FAQs (15 Questions)

  1. What is lorazepam used for?
    It is used to manage anxiety, insomnia, seizures, and for preoperative sedation.
  2. How does lorazepam work?
    It enhances the effects of GABA, a neurotransmitter that calms brain activity.
  3. How long does lorazepam take to work?
    Effects begin within 20–30 minutes when taken orally.
  4. How long does lorazepam last?
    Its effects last 6–8 hours, but it may remain in the body longer.
  5. Can lorazepam cause dependence?
    Yes, prolonged use can lead to physical and psychological dependence.
  6. Is lorazepam safe for children?
    It can be used in specific conditions (e.g., seizures) but requires close monitoring.
  7. Can lorazepam be used during pregnancy?
    It is generally avoided due to potential harm to the foetus.
  8. Can lorazepam be taken with alcohol?
    No, alcohol increases the risk of sedation and respiratory depression.
  9. What are common side effects of lorazepam?
    Common side effects include drowsiness, dizziness, and fatigue.
  10. How should I store lorazepam?
    Store at room temperature, away from moisture and heat, and out of reach of children.
  11. Can lorazepam be stopped suddenly?
    No, sudden discontinuation may cause withdrawal symptoms; taper off gradually.
  12. How should lorazepam be taken for insomnia?
    Take 1–2 mg at bedtime or as prescribed.
  13. What should I do if I miss a dose of lorazepam?
    Take it as soon as you remember unless it’s close to the next dose. Do not double up.
  14. Can lorazepam cause memory problems?
    Yes, it may cause short-term memory issues, especially with high doses.
  15. Is lorazepam safe for elderly patients?
    Yes, but it should be used cautiously at the lowest effective dose to minimise side effects.