Lorazepam Indications and Dosage
- agitation †
- amnesia induction
- anxiety
- ethanol withdrawal †
- insomnia †
- sedation induction
- sedation maintenance †
- seizure prophylaxis †
- status epilepticus †
† non-FDA-approved indication
Lorazepam Indications and Dosage
For the short-term treatment of insomnia † :
Oral dosage:
Adults and adolescents: Usually, 2 - 4 mg PO at bedtime as needed for acute transient stress-related insomnia. In general, not recommended for routine use.
Elderly or debilitated patients: 0.5 - 1 mg PO at bedtime as needed for acute, transient stress-related insomnia. In general, not recommended for routine use. Limit initial dosage to the smallest effective dose in order to reduce the risk of oversedation. According to OBRA guidelines, the total daily dose for long-term care residents for insomnia should not exceed 1 mg/day PO.
For the treatment of anxiety:
- for the routine management of generalized anxiety:
Oral dosage:
Adults and adolescents: Initially, 2 - 3 mg/day PO given in 2 - 3 divided doses. The dosage of lorazepam should be increased gradually when needed to help avoid adverse effects. When higher dosage is indicated, the evening dose should generally be increased before the daytime doses. Dosage may range from 1 - 10 mg/day (usually 2 - 6 mg/day) PO, given in 2 - 3 divided doses.
Elderly or debilitated adult patients: Initially, 1 - 2 mg/day PO given in 2 - 3 divided doses, then increase gradually as needed and tolerated. Limit initial dosage to the smallest effective dose in order to reduce the risk of ataxia or oversedation. According to OBRA guidelines, the total daily dose for long-term care residents should not exceed 2 mg/day PO unless higher dosages are needed to maintain the residents functional status.
Children and infants: Initially 0.05 mg/kg (maximum 2 mg/dose) PO every 4 - 8 hours. The dosage of lorazepam should be increased gradually when needed to help avoid adverse effects. When higher dosage is indicated, the evening dose should be increased before the daytime doses. Dosage may range from 0.02 - 0.1 mg/kg/dose; but no single dose should exceed 2 mg/dose PO.
- as an adjunct to antiemetics in the prevention of chemotherapy-induced nausea/vomiting † and/or relief of pre-chemotherapy anxiety:
Intravenous dosage:
Adults and adolescents: Doses of 0.025 mg/kg IV have been reported to be effective in reducing emesis and anxiety due to chemotherapy with minimal adverse effects. Alternatively, 1.5 mg/m2 (usual max. 3 mg) IV can be given 45 minutes prior to initiation of chemotherapy. Dosage generally produces some amnesia of short-term memory.
Children: 0.04 - 0.08 mg/kg (max: 4 mg) IV every 6 hours as needed. Dosage generally produces some amnesia of short-term memory.
For sedation induction:
- for preoperative sedation induction and/or relief of preoperative anxiety in adults:
Intramuscular or Intravenous dosage:
Adults and adolescents: 0.044 mg/kg IV 15 - 20 minutes prior to surgery or the procedure; maximum dose is 2 mg IV. Alternatively, 0.05 mg/kg IM administered two hours prior to surgery or the procedure; maximum dose is 4 mg IM.
- for operative amnesia induction in adults:
Intravenous dosage:
Adults and adolescents: Up to 0.05 mg/kg IV during surgery or the procedure; maximum dose is 4 mg IV.
- for preprocedure sedation and anxiety relief in children and infants:
Oral, intramuscular, or intravenous dosage:
Children and infants: 0.05 mg/kg PO, IM, or IV (range: 0.02 - 0.09 mg/kg, not to exceed 2 - 4 mg/dose) one hour prior to procedure. Alternatively, for slow titration to effect if the IV route is used, give 0.01 - 0.03 mg/kg IV initially, may repeat every 20 minutes to titrate to desired effect within the hour before procedure.
For sedation maintenance † in mechanically-ventilated patients, to alleviate agitation † and/or anxiety:
Intravenous dosage (intermittent dosage):
Mechanically ventilated adults and adolescents: 0.044 mg/kg (e.g., 2 - 4 mg) IV every 2 - 4 hours, as needed; however, the required dosage is highly variable and should be titrated to desired degree of sedation. A single dose should not exceed 4 mg IV.
Mechanically ventilated children: 0.05 mg/kg IV (range: 0.02 - 0.1 mg/kg) every 4 - 8 hours. Single doses should not exceed 4 mg IV.
Intravenous continuous infusion † dosage:
Mechanically ventilated adults and adolescents: The usual dosage range is 0.5 - 8 mg/hour (or 0.01 - 0.1 mg/kg/hour); titrated to effect. The required dosage is highly variable and should be titrated to desired degree of sedation. A loading dose (i.e., 2 - 4 mg IV) is generally required.
Children: Dosage not established.
For the treatment of status epilepticus † :
Intravenous dosage:
Adults: 4 mg IV given slowly over 2 - 5 minutes. A second dose may be given in 10 - 15 minutes if needed. Maximum dose is 8 mg per any 12-hour period.
Adolescents: 0.07 mg/kg (max: 4 mg) IV given slowly over 2 - 5 minutes. A second dose may be given in 10 - 15 minutes if needed. Maximum dose is 8 mg per any 12-hour period.
Children and infants: 0.1 mg/kg IV given slowly over 2 - 5 minutes. Maximum single dose is 4 mg. A second dose of 0.05 mg/kg IV may be repeated in 10 - 15 minutes if needed.
Neonates: 0.05 mg/kg IV slowly over 2 - 5 minutes. Second dose may be given in 10 - 15 minutes if needed. NOTE: Lorazepam injection contains benzyl alcohol that may be toxic to neonates if given in high doses.
For ethanol withdrawal † :
- for the treatment and prevention of the symptoms of ethanol withdrawal † :
Intravenous, intramuscular, or oral dosage:
Adults: Initially 1 - 2 mg IV, IM, or PO every 8 hours. Titrate dose for desired clinical response. Maximum single dose is 4 mg. Decrease the dose after 1 - 2 days of therapy as clinically indicated and tolerated. NOTE: Dosing is highly variable in this condition. Cases have been reported where some patients required massive doses of benzodiazepines during the acute phase of ethanol withdrawal. Intravenous diazepam doses of 270 mg over 45 minutes and 2335 mg over a period of 4 days have been reported.
- for acute ethanol-related seizure prophylaxis † :
Intravenous dosage:
Adults: One study has reported that a single dose of lorazepam 2 mg IV given within 6 hours of a witnessed ethanol-related seizure may significantly reduce the recurrence of a second seizure, and decrease the need for hospitalization.
Maximum Dosage Limits:
- Adults: Maximum dose highly variable dependent upon indication.
- Elderly: Federal OBRA guidelines recommend that the dose not exceed 1 mg/day PO for insomnia and 2 mg/day PO for anxiety in residents of skilled nursing facilities.
- Adolescents: Safe and effective use has not been established.
- Children: Safe and effective use has not been established.
Patients with hepatic impairment:
Lorazepam undergoes glucuronidation in the liver to inactive metabolites; studies in patients with cirrhosis or other significant liver disease do not generally note a need for dose reduction.
Patients with renal impairment:
Dosage should be modified depending on clinical response and degree of renal impairment, but no quantitative recommendations are available.
† non-FDA-approved indication
[ Last revised: 2/7/2006 10:22:00 AM ]
References
. Woo E, Greenblatt DJ. Massive benzodiazepine requirements during acute alcohol withdrawal. Am J Psychiatry 1979;136:821 - 3.
. Laszlo J, Clark RA, Hanson DC et al. Lorazepam in cancer patients treated with cisplatin: a drug having antiemetic, amnestic and anxiolytic effects. J Clin Oncol 1985;3:864 - 9.
. Shapiro BA, Warren J, Egol AB, et al. Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit. Crit Care Med 1995;23:1596 - 1600.
. D’Onofrio G, Rathlev NK, Ulrich AS, et al. Lorazepam for the prevention of recurrent seizures related to alcohol. N Engl J Med 1999;340:915 - 9.
. Gurvich T, Cunningham JA. Appropriate Use of Psychotropic Drugs in Nursing Homes. Am Fam Physician 2000;61:1437 - 46.
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