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# Lorazepam
## Overview
Lorazepam is a high-potency, intermediate-acting benzodiazepine that acts as a positive allosteric modulator of the $\text{GABA}_A$ receptor, increasing chloride conductance and inducing CNS depression.
## Primary Indications
* Anxiety disorders (short-term management)
* Status epilepticus (first-line)
* Preoperative sedation/anxiolysis
* Acute alcohol withdrawal syndrome
## Adult Dosing
* **Anxiety:** 1–3 mg orally daily in 2–3 divided doses. Maximum: 10 mg/day.
* **Insomnia:** 2–4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg IV/IM (slow push, max rate 2 mg/min). May repeat once in 10–15 minutes if seizures persist.
* **Preoperative Sedation:** 0.044 mg/kg (max 2 mg) IV administered 15–20 minutes prior to procedure.
## Pediatric Dosing
* **Status Epilepticus:** 0.05–0.1 mg/kg IV/IM (slow push). Maximum single dose 4 mg. May repeat once in 10–15 minutes.
* *Note: Dosing often varies based on institution-specific status epilepticus protocols.*
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; clearance is generally preserved (unlike diazepam), but sensitivity to sedation is increased. Start at lower doses.
* **Renal Impairment:** No specific adjustment required for lorazepam itself, but use caution due to accumulation of inactive glucuronide metabolites in severe cases.
* **Geriatric/Debilitated:** Reduce initial dose by 50% and titrate slowly due to increased risk of ataxia and oversedation.
## Contraindications
* Known hypersensitivity to benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency or sleep apnea (without ventilatory support).
* Myasthenia gravis (relative).
## Adverse Effects
* **Common:** Sedation, dizziness, ataxia, fatigue, anterograde amnesia.
* **Serious:** Paradoxical agitation (more common in pediatrics/geriatrics), respiratory depression, physical dependence, and withdrawal syndrome upon abrupt cessation.
## Key Drug Interactions
* **CNS Depressants:** Significant additive effects with opioids, alcohol, and other sedatives (risk of fatal respiratory depression).
* **Opioids:** The FDA has issued a Black Box Warning for the concurrent use of benzodiazepines and opioids; avoid unless no alternative treatments exist.
* **Valproate:** May inhibit glucuronidation, increasing lorazepam serum concentrations.
## Monitoring
* **Baseline/Ongoing:** Respiratory rate, oxygen saturation, level of sedation, and blood pressure.
* **Long-term:** Signs of abuse, misuse, or dependence. Monitor for paradoxical reactions upon initiation.
## Clinical Pearls
* **IV vs. IM:** Lorazepam is consistently absorbed via the IM route, unlike diazepam. IM injection should be diluted with an equal volume of sterile NS or SWFI to decrease viscosity and pain.
* **Onset:** Slower onset of action compared to diazepam (which is more lipophilic and rapidly crosses the blood-brain barrier); therefore, lorazepam is less likely to produce a rapid "euphoric" effect.
* **Compatibility:** Often incompatible with many IV medications. Consult local Y-site compatibility charts or facility resources.
* **Withdrawal:** Taper dose gradually after chronic therapy (e.g., >2 weeks) to prevent seizures or rebound anxiety.
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*Disclaimer: This information is for educational purposes only. Clinical practice varies by institution and patient-specific factors. Always verify current prescribing information, institutional protocols, and contraindications via official references such as Lexicomp, Micromedex, or the package insert before prescribing or administering medication.*
