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# Lorazepam
## Overview
Lorazepam is a high-potency, intermediate-acting benzodiazepine. It acts as a positive allosteric modulator of the $\text{GABA}_A$ receptor, enhancing the inhibitory effects of GABA in the central nervous system. It exhibits anxiolytic, sedative, anticonvulsant, and muscle-relaxant properties.
## Primary Indications
* Anxiety disorders (short-term management)
* Status epilepticus (first-line)
* Preoperative sedation
* Insomnia
* Acute alcohol withdrawal
## Adult Dosing
* **Anxiety:** 1 to 3 mg orally 2–3 times daily.
* **Status Epilepticus:** 4 mg (or 0.1 mg/kg) IV slow push; may repeat once after 10–15 minutes if seizures continue (max 8 mg total).
* **Insomnia:** 2 to 4 mg at bedtime.
* **Preoperative Sedation:** 0.05 mg/kg (max 4 mg) IV or IM administered 2 hours before surgery.
## Pediatric Dosing
* **Status Epilepticus:** 0.1 mg/kg IV/IO (max 4 mg per dose). May repeat once after 10–15 minutes.
* **Procedural Sedation/Anxiety:** 0.05 mg/kg IV/IM (max 2 mg).
* *Note: Dosing varies by institutional protocol; verify age-specific guidelines in critical care settings.*
## Dose Adjustments
* **Hepatic Impairment:** Reduce dose in patients with cirrhosis/severe impairment; monitor for increased sensitivity. Lorazepam is preferred over diazepam because it is metabolized via glucuronidation and not hepatic CYP450 enzymes.
* **Renal Impairment:** No standard adjustment, but use caution; inactive metabolites may accumulate.
* **Geriatrics:** Start at the lowest possible dose (e.g., 0.5 mg) due to increased sensitivity to sedation and fall risk.
## Contraindications
* Known hypersensitivity to benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency (except in the context of mechanical ventilation).
* Myasthenia gravis.
## Adverse Effects
* **Common:** Drowsiness, dizziness, ataxia, confusion, and fatigue.
* **Serious:** Respiratory depression (especially with co-administration of opioids), paradoxical excitement, hypotension, and anterograde amnesia.
* **Withdrawal:** Risk of seizures and rebound anxiety with abrupt cessation after long-term use.
## Key Drug Interactions
* **CNS Depressants:** Significant risk of profound sedation, respiratory depression, and coma when combined with opioids, alcohol, or other sedative-hypnotics.
* **Valproic Acid:** May inhibit the metabolism of lorazepam, increasing serum levels.
* **Scopolamine:** Increased risk of sedation and hallucinations.
## Monitoring
* **Critical:** Respiratory rate, pulse oximetry, and blood pressure (especially with IV administration).
* **Long-term:** Mental status, signs of abuse/misuse, and liver function.
* **Emergency:** Presence of resuscitation equipment and flumazenil (available as a reversal agent, though use cautiously due to seizure risk).
## Clinical Pearls
* **IV Administration:** Dilute IV push doses with an equal volume of compatible diluent (e.g., sterile water or NS) and inject at a rate not exceeding 2 mg/min.
* **Metabolism:** Lorazepam undergoes simple glucuronidation into inactive metabolites, making it safer for patients with liver disease compared to benzodiazepines that undergo oxidative metabolism.
* **Onset:** IV onset is typically 5–15 minutes. IM absorption is erratic and slower; avoid IM if possible unless IV/IO access is impossible.
* **Tapering:** Always taper doses slowly following chronic use to prevent withdrawal syndromes.
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**Educational Disclaimer:** This summary is for educational purposes and does not replace professional clinical judgment. Always verify current prescribing information, institutional protocols, and patient-specific factors before administering medication. In the event of an overdose or adverse reaction, consult your institution's poison control center or emergency services.
