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# Lorazepam
## Overview
Lorazepam is a high-potency, intermediate-acting benzodiazepine that acts as a positive allosteric modulator of the $GABA_A$ receptor. It features a relatively rapid onset (IV) and lacks active metabolites, making it preferred in patients with hepatic impairment.
## Primary Indications
* Anxiety disorders (short-term management)
* Status epilepticus (first-line)
* Preoperative sedation/anxiolysis
* Insomnia
* Acetaldehyde/Alcohol withdrawal syndrome
## Adult Dosing
* **Anxiety:** 1–3 mg orally daily in 2–3 divided doses. Maximum dose is typically 10 mg/day.
* **Insomnia:** 2–4 mg orally at bedtime.
* **Status Epilepticus:** 4 mg IV (rate ≤2 mg/min); may repeat dose once after 10–15 minutes if seizures persist.
* **Preoperative Sedation:** 0.044 mg/kg IV (not to exceed 2 mg) or 2 mg IM.
## Pediatric Dosing
* **Status Epilepticus:** 0.05–0.1 mg/kg IV/IO (max single dose 4 mg); may repeat dose once after 10–15 minutes.
* **Anxiety/Sedation:** 0.05 mg/kg orally or IV (max 2 mg/dose).
* *Note: Dosing for status epilepticus is often dictated by local pediatric emergency protocols; verify specific facility weight-based charts.*
## Dose Adjustments
* **Hepatic Impairment:** Lorazepam is preferred over other benzodiazepines as it undergoes direct glucuronidation. However, use caution and reduce initial dose by 50% in severe impairment.
* **Renal Impairment:** No standard adjustment required, but use caution due to sensitivity to CNS effects.
* **Geriatric Patients:** Start at the lowest possible dose (e.g., 0.5 mg) due to increased risk of falls, delirium, and cognitive impairment.
## Contraindications
* Known hypersensitivity to benzodiazepines.
* Acute narrow-angle glaucoma.
* Severe respiratory insufficiency or sleep apnea (without ventilatory support).
* Myasthenia gravis.
## Adverse Effects
* **Common:** Drowsiness, dizziness, ataxia, confusion, fatigue.
* **Serious:** Respiratory depression (especially with co-administration of opioids), hypotension, paradoxical reactions (agitation, aggression), and physical dependence/withdrawal syndrome upon abrupt cessation.
## Key Drug Interactions
* **Opioids:** Profound risk of respiratory depression, coma, and death. Avoid concomitant use unless absolutely necessary; if unavoidable, use the lowest effective dose for the shortest duration.
* **CNS Depressants:** Increased risk of sedation and respiratory depression with alcohol, barbiturates, or antipsychotics.
* **Valproate:** May inhibit glucuronidation, increasing lorazepam plasma concentrations.
## Monitoring
* **Clinical:** Respiratory rate, oxygen saturation, level of consciousness (RASS score), and seizure cessation.
* **Long-term:** Monitor for signs of substance abuse, misuse, or dependence.
## Clinical Pearls
* **Injection Storage:** IV/IM lorazepam must be refrigerated (2°C to 8°C). If kept at room temperature, it is stable for 30 days only.
* **Administration:** When administering IV, inject slowly to avoid hypotension.
* **Withdrawal:** Taper slowly after long-term use to prevent benzodiazepine withdrawal syndrome, which can include tremors, tachycardia, and grand mal seizures.
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*Disclaimer: This information is for educational purposes and does not replace professional clinical judgment. Always verify current prescribing information, institutional protocols, and patient-specific factors before administration.*
