lorazepam

ROUTE	ONSET	PEAK	DURATION
PO	15–60 min	1–6 hr	8–12 hr
PO-XR	unknown	unknown	unknown
IM	30–60 min	1–2 hr‡	8–12 hr
IV	15–30 min	15–20 min	8–12 hr

Contraindicated in:

Hypersensitivity;
Cross-sensitivity with other benzodiazepines may exist;
Comatose patients or those with pre-existing CNS depression;
Uncontrolled severe pain;
Angle-closure glaucoma;
Severe hypotension;
Sleep apnea.

Use Cautiously in:

Severe hepatic impairment;
Severe renal impairment;
Severe lung disease;
Myasthenia gravis;
Depression;
Psychosis;
History of suicide attempt or drug abuse/substance use disorder;
COPD;
Sleep apnea;
OB: Use late in pregnancy can result in sedation (respiratory depression, lethargy, hypotonia) and/or withdrawal symptoms (hyperreflexia, irritability, restlessness, tremors, inconsolable crying, feeding difficulties) in neonates;
Lactation: Use while breastfeeding only if potential maternal benefit outweighs potential risk to infant;
Pedi: Safety and effectiveness not established in children <18 yr (IV) or <12 yr (PO); in ↑ doses, benzyl alcohol in injection may cause potentially fatal gasping syndrome in neonates; IV use may affect brain development in children <3 yr;
Geri: Appears on Beers list. ↑ risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. If possible, avoid use in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: bradycardia, hypotension, rapid IV use onlyAPNEA, CARDIAC ARREST

Derm: rash

EENT: blurred vision

GI: constipation, diarrhea, nausea, vomiting

Neuro: dizziness, drowsiness, lethargy, ataxia, confusion, forgetfulness, hangover, headache, mental depression, rhythmic myoclonic jerking (in preterm infants), paradoxical excitation, slurred speech

Resp: RESPIRATORY DEPRESSION

Misc: physical dependence, psychological dependence, tolerance

Interactions ⬆ ⬇

Drug-drug:

Use with opioids or other CNS depressants, including other benzodiazepines, nonbenzodiazepine sedative/hypnotics, anxiolytics, general anesthetics, muscle relaxants, antipsychotics, and alcohol, may cause profound sedation, respiratory depression, coma, and death; reserve concurrent use for when alternative treatment options are inadequate.
May ↓ the efficacy of levodopa.
Smoking may ↓ levels and effectiveness.
Valproate and probenecid may ↑ levels and risk of toxicity; ↓ dose by 50%.
Oral contraceptives may ↓ levels and effectiveness.

Drug-Natural Products:

kava-kava, valerian, or chamomile may ↑ risk of CNS depression.

Route/Dosage ⬆ ⬇

Status Epilepticus

IV IM (Adults ): 4 mg; may be repeated after 10–15 min.

Preanesthetic

IM (Adults ): 0.05 mg/kg (not to exceed 4 mg) ≥2 hr before surgery.
IV (Adults ): 0.044 mg/kg (not to exceed 2 mg) 15–20 min before surgery.

Anxiety

PO (Adults ): Immediate-release tablets: 1–3 mg 2–3 times daily (up to 10 mg/day). Extended-release capsules: Give total daily dose of lorazepam immediate-release tablets (at the previous three times daily dose) and administer once daily in the morning. If dose ↑ needed, switch to lorazepam immediate-release tablets to ↑ the dose; once stable response achieved, may switch back to equivalent daily dose of lorazepam extended-release capsules.
PO Geriatric Patients or Debilitated Patients): 0.5–2 mg/day in divided doses initially.

Availability ⬆ ⬇

(Generic available)

Immediate-release tablets: 0.5 mg; 1 mg; 2 mg
Extended-release capsules (Loreev XR): 1 mg; 1.5 mg; 2 mg; 3 mg
Concentrated oral solution: 2 mg/mL
Solution for injection: 2 mg/mL; 4 mg/mL

Assessment ⬆ ⬇

Assess continued need for therapy regularly.
Assess risk for addiction, abuse, or misuse before administration and periodically during therapy.
Monitor respiratory function during therapy. If signs and symptoms of respiratory depression or apnea occur, consider discontinuing lorazepam.
Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict the amount of drug available to patient. Assess regularly for continued need for treatment.
Geri: Assess older adults carefully for CNS reactions and fall risk.
Anxiety: Monitor degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy.
Status Epilepticus: Assess location, duration, characteristics, and frequency of seizures. Institute seizure precautions.

Lab Test Considerations:

Patients on high-dose therapy should receive routine evaluation of renal, hepatic, and hematologic function.
May cause leukopenia.
May ↑ lactate dehydrogenase.

Toxicity and Overdose:

If overdose occurs, flumazenil is the antidote. Do not use with patients with seizure disorder. May induce seizures.

Implementation ⬆ ⬇

Do not confuse lorazepam with alprazolam, clonazepam, or Lovaza.
- Gradually taper to discontinue or ↓ dose to ↓ risk of withdrawal reactions, seizures, and status epilepticus. If a patient develops withdrawal reactions, consider pausing taper or ↑ dose to previous tapered dose level. Subsequently ↓ dose more slowly. Some patients may require longer tapering period (weeks to >12 mo).
- Following parenteral administration, keep patient supine for ≥8 hr and observe closely.
PO: Tablet may also be given sublingually (unlabeled) for more rapid onset.
Administer XR capsules with or without food. DNC: Do not crush or chew. Swallow whole or open and sprinkle the entire contents of capsule over a tablespoon of applesauce; then drink water after consuming the applesauce (without chewing). Consume entire contents of capsule within 2 hr of opening capsule.
Take concentrated liquid solution with water, soda, pudding, or applesauce. Use calibrated dropper provided to ensure accurate dose.
IM: Administer IM doses deep into muscle mass ≥2 hr before surgery for optimum effect.

IV Administration:

Vesicant: IV lorazepam is a vesicant. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient’s extremity and apply dry cold compresses.
IV Push: Diluent: Dilute immediately before use with an equal amount of sterile water for injection, D5W, or 0.9% NaCl for injection.Pedi: To ↓ the amount of benzyl alcohol delivered to neonates, dilute the 4 mg/mL injection with preservative-free sterile water for injection to make a 0.4 mg/mL dilution for IV use. Do not use if solution is discolored or contains particulates.
Rate: Administer at a rate not to exceed 2 mg/min or 0.05 mg/kg over 2–5 min. Rapid IV administration may result in apnea, hypotension, bradycardia, or cardiac arrest.
Y-Site Compatibility:
- acetaminophen
- acyclovir
- albumin
- alemtuzumab
- allopurinol
- amikacin
- aminocaproic acid
- aminophylline
- amiodarone
- amphotericin B deoxycholate
- anakinra
- anidulafungin
- argatroban
- arsenic trioxide
- atracurium
- azithromycin
- bleomycin
- bumetanide
- buprenorphine
- busulfan
- butorphanol
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- carmustine
- cefazolin
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftaroline
- ceftazidime
- ceftobiprole
- ceftolozane/tazobactam
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- cladribine
- clindamycin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
- daptomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- dimenhydrinate
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxorubicin hydrochloride
- doxorubicin liposomal
- doxycycline
- droperidol
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
- eptifibatide
- ertapenem
- erythromycin
- esmolol
- etomidate
- etoposide phosphate
- famotidine
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- fosphenytoin
- furosemide
- ganciclovir
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- haloperidol
- heparin
- hydrocortisone
- hydromorphone
- ifosfamide
- insulin regular
- irinotecan
- isavuconazonium
- isoproterenol
- ketorolac
- labetalol
- leucovorin
- lidocaine
- linezolid
- magnesium sulfate
- mannitol
- melphalan
- meropenem
- meropenem/vaborbactam
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- micafungin
- midazolam
- milrinone
- mitoxantrone
- morphine
- mycophenolate
- nafcillin
- nalbuphine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- oritavancin
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- pemetrexed
- pentamidine
- pentobarbital
- phenobarbital
- phentolamine
- phenylephrine
- piperacillin/tazobactam
- plazomicin
- posaconazole
- potassium acetate
- potassium chloride
- procainamide
- prochlorperazine
- promethazine
- propofol
- propranolol
- remifentanil
- rituximab
- sodium acetate
- sodium bicarbonate
- sodium phosphates
- succinylcholine
- sulbactam/durlobactam
- tacrolimus
- tedizolid
- theophylline
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- trastuzumab
- trimethoprim/sulfamethoxazole
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zidovudine
- zoledronic acid
Y-Site Incompatibility:
- aldesleukin
- amphotericin B liposomal
- ampicillin
- ampicillin/sulbactam
- aztreonam
- dantrolene
- fluorouracil
- gemtuzumab ozogamicin
- hydralazine
- idarubicin
- imipenem/cilastatin
- letermovir
- meperidine
- mitomycin
- omeprazole
- ondansetron
- pantoprazole
- phenytoin
- potassium phosphates
- rocuronium
- sargramostim
- sufentanil

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy.
Instruct patient to take medication exactly as directed and not to skip or double up on missed doses. If medication is less effective after a few weeks, notify health care provider; do not ↑ dose.
Caution patient not to stop taking lorazepam without consulting health care provider. Abrupt withdrawal may cause sweating, vomiting, muscle cramps, tremors, and seizures; may be life-threatening.
Caution patient to notify health care provider immediately if unusual movements, seizures, sudden and severe mental or nervous system changes, depression, hallucinations, an extreme ↑ in activity or talking, or suicidal ideas or actions occur.
Advise patient that lorazepam is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was prescribed. Store out of sight and reach of children and in a location not accessible by others.
Advise patient that lorazepam is usually prescribed for short-term use and does not cure underlying problem.
May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to avoid the use of alcohol or other CNS depressants, including opioids, concurrently with lorazepam; may cause respiratory depression and overdose. Instruct patient to consult health care provider before taking Rx, OTC, or herbal products concurrently with this medication.
Rep: May cause fetal harm. Advise women of reproductive potential to notify health care provider immediately if pregnancy is planned or suspected or if breastfeeding. Monitor infants exposed to lorazepam during pregnancy or labor for several weeks or more prior to delivery for signs and symptoms of withdrawal (hypoactivity, hypotonia, hypothermia, respiratory depression, apnea, feeding problems, impaired metabolic response to cold stress). Notify health care provider immediately if sedation, poor feeding, or poor weight gain occurs in infants exposed to lorazepam during breastfeeding. Notify patient about the National Pregnancy Registry for Psychiatric Medications, which monitors outcomes in women exposed to psychiatric medications, including lorazepam, during pregnancy. Health care providers are encouraged to register patients by calling 1-866-961-2388 or visiting https://womensmentalhealth.org/pregnancyregistry/.
Emphasize the importance of follow-up exams to determine effectiveness of therapy.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Contr. Subst. Schedule ⬆ ⬇

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