Please check your internet connection and try again.
# Lorazepam
## Overview
Lorazepam is a high-potency, intermediate-acting benzodiazepine that acts as a positive allosteric modulator of the GABA-A receptor. It is preferred in patients with hepatic impairment due to its metabolism via direct glucuronidation, bypassing the CYP450 system.
## Primary Indications
* Anxiety disorders (short-term management)
* Status epilepticus (first-line)
* Preoperative sedation/anxiolysis
* Insomnia
* Alcohol withdrawal syndrome
## Adult Dosing
* **Anxiety:** 2–6 mg/day orally in divided doses. Maximum 10 mg/day.
* **Insomnia:** 2–4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg IV bolus (at rate $\leq$ 2 mg/min); may repeat dose of 2–4 mg after 10–15 minutes if seizures persist.
* **Preoperative Sedation:** 0.05 mg/kg (up to 4 mg max) IM 2 hours before surgery or 0.044 mg/kg (up to 2 mg max) IV 15–20 minutes before surgery.
## Pediatric Dosing
* **Status Epilepticus:** 0.05–0.1 mg/kg IV/IO (max 4 mg per dose). May repeat once after 10–15 minutes.
* **Sedation:** 0.05 mg/kg IM/IV (max 2 mg per dose).
* *Note: Dosing depends heavily on facility-specific pediatric protocols and weight-based tables.*
## Dose Adjustments
* **Hepatic Impairment:** Generally safe due to glucuronidation, but use lower initial doses in severe impairment due to increased sensitivity to sedative effects.
* **Renal Impairment:** No initial adjustment required; monitor for sedation as active metabolites or lorazepam-glucuronide can accumulate.
* **Geriatric:** Reduce initial dose by 50% due to increased risk of falls, cognitive impairment, and paradoxical reactions.
## Contraindications
* Hypersensitivity to benzodiazepines
* Acute narrow-angle glaucoma
* Severe respiratory insufficiency
* Sleep apnea
* Myasthenia gravis
## Adverse Effects
* **Common:** Sedation, dizziness, ataxia, weakness, fatigue.
* **Serious:** Respiratory depression (especially with opioids), anterograde amnesia, dependence, and paradoxical reactions (agitation, hallucinations).
## Key Drug Interactions
* **CNS Depressants:** Potentiates effects of opioids, alcohol, and other sedatives; severe risk of respiratory depression and death.
* **Valproate:** May inhibit glucuronidation, decreasing lorazepam clearance and increasing serum levels.
## Monitoring
* **Immediate:** Respiratory rate, pulse oximetry, blood pressure, and mental status (sedation level).
* **Long-term:** Monitor for signs of physical dependence, tolerance, and misuse.
## Clinical Pearls
* **Withdrawal:** Avoid abrupt discontinuation after chronic use; taper slowly to prevent seizures and withdrawal syndrome.
* **IV Administration:** Must be diluted 1:1 with compatible solution (normal saline or D5W) for immediate injection.
* **Paradoxical Effects:** Older adults and patients with developmental disabilities are at higher risk for paradoxical hyper-excitability; discontinue if this occurs.
* **Storage:** IV/IM vials require refrigeration to maintain potency.
***
**Disclaimer:** This information is for educational purposes only. Clinical practice varies by institution. Always verify dosages, contraindications, and drug interactions using current, peer-reviewed clinical decision support systems or local institutional guidelines before prescribing or administering medication.
