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Ativan
lorazepam
Black Box Warnings .
Risks from Concomitant Opioid Use
concomitant benzodiazepine use w/ opioids may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for pts w/ inadequate alternative tx options; limit to minimum required dosage and duration; monitor pts for s/sx of resp. depression and sedation
Addiction, Abuse, and Misuse
benzodiazepines expose users to risk of abuse, misuse, and addiction, can lead to overdose or death; commonly involves concomitant use w/ other meds, alcohol, and/or illicit substances, which is assoc. w/ incr. frequency of serious adverse outcomes; assess risk for abuse, misuse, and addiction before prescribing and throughout tx
Dependence and Withdrawal Reactions
cont. benzodiazepine use may lead to clinically significant physical dependence; risk of dependence and withdrawal incr. w/ longer tx duration and higher daily dose; use gradual taper to D/C after cont. use as abrupt D/C or rapid dose reduction may cause acute withdrawal reactions, potentially life-threatening
Adult Dosing .
Dosage forms: TAB: 0.5 mg, 1 mg, 2 mg; INJ: 2 mg per mL, 4 mg per mL
anxiety
- [2-6 mg/day PO/IM/IV divided bid-tid]
- Start: 2-3 mg/day PO/IM/IV divided bid-tid; Max: 10 mg/day; Info: start 1-2 mg/day PO/IM/IV divided bid-tid in elderly or debilitated pts; taper dose gradually to D/C; search 'benzodiazepine' for epocrates Benzodiazepine Deprescribing Advice decision tool
insomnia, short-term tx
- [2-4 mg PO qhs prn]
- Info: taper dose gradually to D/C; search 'benzodiazepine' for epocrates Benzodiazepine Deprescribing Advice decision tool
status epilepticus
- [4 mg IV x1]
- Info: may repeat x1 after 10-15min
preoperative sedation
- [IM route]
- Dose: 0.05 mg/kg/dose IM x1; Start: >2h before surgery; Max: 4 mg/dose
- [IV route]
- Dose: 0.044-0.05 mg/kg/dose IV x1; Start: 15-20min before surgery; Max: 4 mg/dose; Info: max 2 mg/dose in elderly pts
chemo-related nausea/vomiting, adjunct tx (off-label)
- [0.5-1 mg PO/IV q6h prn]
- Info: give w/ antiemetic; use lowest effective dose, shortest effective tx duration
alcohol withdrawal, acute (off-label)
- [fixed-dose regimen]
- Dose: 2 mg PO/IM/IV q8h x2 days, then 1 mg PO/IM/IV q8h x1 day, then 1 mg PO/IM/IV q12h x1 day, then 1 mg PO/IM/IV qhs x1 day; Info: give additional doses prn; refer to institution protocol
- [symptom-triggered regimen]
- Dose: 2-4 mg PO/IM/IV q1h prn; Info: refer to institution protocol
delirium tremens (off-label)
- [1-4 mg IV q5-15min prn]
- Alt: 1-4 mg IM q30-60min prn; Info: refer to institution protocol
neuroleptic malignant syndrome (off-label)
- [1-2 mg IM/IV q4-6h]
renal dosing
- [PO route]
- renal impairment: no adjustment
- HD/PD: not defined
- [IM/IV route]
- renal failure: avoid use; Info: caution advised if freq. or high-dose use in renal impairment due to incr. risk of propylene/polyethylene glycol toxicity
- HD/PD: not defined
hepatic dosing
- [PO route]
- severe impairment: consider decr. usual dose
- [IM/IV route]
- hepatic impairment: not defined, caution advised; hepatic failure: avoid use
Peds Dosing .
- Dosage forms: TAB: 0.5 mg, 1 mg, 2 mg; INJ: 2 mg per mL, 4 mg per mL
anxiety (off-label)
- [children]
- Dose: 0.05 mg/kg/dose PO/IV q4-8h; Max: 2 mg/dose; Info: taper dose gradually to D/C; search 'benzodiazepine' for epocrates Benzodiazepine Deprescribing Advice decision tool
status epilepticus (off-label)
- [0.05-0.1 mg/kg/dose IV x1]
- Max: 4 mg/dose; Info: may repeat x1 after 10-15min
chemo-related nausea/vomiting, adjunct tx (off-label)
- [children]
- Dose: 0.02-0.05 mg/kg/dose IV q6h prn; Max: 2 mg/dose; Info: give w/ antiemetic; use lowest effective dose, shortest effective tx duration
preoperative sedation (off-label)
- [children]
- Dose: 0.05 mg/kg/dose PO/IM/IV x1; Start: PO 1h, IM >2h, IV 15-20min before surgery; Max: 2 mg/dose
renal dosing
- [PO route]
- renal impairment: no adjustment
- HD/PD: not defined
- [IM/IV route]
- renal failure: avoid use; Info: caution advised if freq. or high-dose use in renal impairment due to incr. risk of propylene/polyethylene glycol toxicity
- HD/PD: not defined
hepatic dosing
- [not defined]
- hepatic impairment: consider adult hepatic dosing for guidance
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- hypersensitivity to propylene glycol (INJ form)
- hypersensitivity to polyethylene glycol (INJ form)
- intra-arterial use
- neonates (benzyl alcohol-containing INJ form)
- infants (benzyl alcohol-containing INJ form)
- renal failure (IM or IV use)
- hepatic failure (IM or IV use)
- respiratory impairment, severe (IM or IV use)
- sleep apnea (IM or IV use)
- glaucoma, narrow-angle
- abrupt withdrawal
- avoid: alcohol use
- caution: CNS depressant use, concurrent
- caution: CNS depression
- caution: alcohol abuse hx
- caution: drug abuse hx
- caution: elderly pts
- caution: debilitated pts
- caution: pts <3 yo (repeat sedation or >3h use)
- caution: renal impairment (IM or IV use)
- caution: hepatic impairment (IM or IV use)
- caution: hepatic impairment, severe (PO use)
- caution: pulmonary impairment
- caution: seizure hx
- caution: depression
- caution: psychosis
Drug Interactions .
Overview
lorazepam
benzodiazepine
- UGT2B4 substrate
- UGT2B7 substrate
- antiepileptic agent
- CNS depression
- hypotensive effects
Contraindicated
- amifampridine
- bupropion
- dalfampridine
- metoclopramide
Avoid/Use Alternative
- alfentanil
- alprazolam
- aripiprazole lauroxil
- brexanolone
- buprenorphine
- butalbital
- butorphanol
- cannabidiol
- chlordiazepoxide
- clobazam
- clonazepam
- clorazepate
- codeine
- daridorexant
- diazepam
- dihydrocodeine
- doxylamine
- esketamine
- estazolam
- ethanol
- ethanol (in some formulations)
- fentanyl
- fluconazole
- gabapentin
- gabapentin enacarbil
- ginkgo
- hydrocodone
- hydromorphone
- imatinib
- isocarboxazid
- kava
- kratom
- levorphanol
- lindane topical
- meperidine
- metaxalone
- methadone
- midazolam
- morphine
- nalbuphine
- olanzapine
- oliceridine
- opium
- oxazepam
- oxybate
- oxycodone
- oxymorphone
- pentazocine
- phenelzine
- pregabalin
- probenecid
- promethazine
- quazepam
- remimazolam
- ropeginterferon alfa-2b
- suvorexant
- tapentadol
- temazepam
- thalidomide
- tramadol
- tranylcypromine
- triazolam
- valproic acid
- zuranolone
Monitor/Modify Tx
- 5-HTP
- aldesleukin
- allopurinol
- almotriptan
- amantadine
- amitriptyline
- amoxapine
- apomorphine
- apraclonidine ophthalmic
- aripiprazole
- aripiprazole bimonthly injection
- asenapine
- baclofen
- baclofen intrathecal
- brexpiprazole
- brimonidine ophthalmic
- brimonidine topical
- brivaracetam
- bromocriptine
- brompheniramine
- buspirone
- cannabis
- carbamazepine
- carbinoxamine
- cariprazine
- carisoprodol
- cenobamate
- cetirizine
- chamomile, German
- chlorpheniramine
- chlorpromazine
- chlorzoxazone
- citalopram
- clemastine
- clomipramine
- clonidine
- clozapine
- cyclobenzaprine
- cyproheptadine
- dantrolene
- darifenacin
- desflurane
- desipramine
- desvenlafaxine
- deutetrabenazine
- dexchlorpheniramine
- dexmedetomidine
- dexmedetomidine injection
- dichlorphenamide
- difelikefalin
- difenoxin
- dimenhydrinate
- diphenhydramine
- diphenoxylate
- domperidone
- doxepin
- doxepin topical
- dronabinol
- droperidol
- duloxetine
- efavirenz
- eletriptan
- entacapone
- entrectinib
- escitalopram
- eslicarbazepine acetate
- eszopiclone
- ethinyl estradiol (contraceptive)
- ethosuximide
- etomidate
- felbamate
- fenfluramine
- fesoterodine
- flibanserin
- fluoxetine
- fluphenazine
- fluvoxamine
- fosphenytoin
- frovatriptan
- ganaxolone
- glofitamab
- glycopyrrolate
- guanfacine
- haloperidol
- hydroxyzine
- hyoscyamine
- ifosfamide
- iloperidone
- imipramine
- isoflurane
- ketamine
- lacosamide
- lamotrigine
- lasmiditan
- lemborexant
- levetiracetam
- levocetirizine
- levodopa
- levomilnacipran
- lofexidine
- loxapine
- lumateperone
- lurasidone
- meclizine
- melatonin
- meprobamate
- methocarbamol
- methohexital
- methsuximide
- methyldopa
- metyrapone
- metyrosine
- milnacipran
- mirtazapine
- mitotane
- molindone
- mosunetuzumab
- mycophenolate mofetil
- naltrexone
- naratriptan
- nefazodone
- nelarabine
- nortriptyline
- opicapone
- orphenadrine
- oxcarbazepine
- oxybutynin
- paliperidone
- paroxetine
- passion flower
- pentobarbital
- perampanel
- perphenazine
- pheniramine
- phenobarbital
- phenylephrine injection
- phenytoin
- pimozide
- pramipexole
- primidone
- procarbazine
- prochlorperazine
- propofol
- protriptyline
- pyrilamine
- quetiapine
- ramelteon
- rasagiline
- remifentanil
- repotrectinib
- risperidone
- rizatriptan
- ropinirole
- rotigotine transdermal
- rufinamide
- safinamide
- scopolamine
- selegiline
- selegiline transdermal
- selinexor
- sertraline
- sevoflurane
- solifenacin
- stiripentol
- sufentanil
- sumatriptan
- tasimelteon
- tetrabenazine
- thioridazine
- thiothixene
- tiagabine
- tizanidine
- tolcapone
- tolterodine
- topiramate
- trazodone
- trifluoperazine
- trihexyphenidyl
- trimethobenzamide
- trimipramine
- triprolidine
- trospium
- valbenazine
- valerian
- venlafaxine
- vigabatrin
- vilazodone
- viloxazine
- zaleplon
- ziconotide
- ziprasidone
- zolmitriptan
- zolpidem
- zonisamide
Caution Advised
- acyclovir
- aminophylline
- amoxicillin
- amphetamine
- ampicillin
- apalutamide
- axicabtagene ciloleucel
- benzphetamine
- betamethasone
- brexucabtagene autoleucel
- busulfan
- cefazolin
- cefepime
- cefiderocol
- ceftaroline fosamil
- ceftazidime
- chlorambucil
- chloroquine
- ciltacabtagene autoleucel
- ciprofloxacin
- cisatracurium
- cocaine
- cortisone
- cyclosporine
- darbepoetin alfa
- darolutamide
- deflazacort
- delafloxacin
- dexamethasone
- dexmethylphenidate
- dextroamphetamine
- dicloxacillin
- diethylpropion
- donepezil
- elivaldogene autotemcel
- enzalutamide
- ephedra
- epoetin alfa
- ertapenem
- foscarnet
- galantamine
- ganciclovir
- goserelin
- histrelin
- hydroxychloroquine
- idecabtagene vicleucel
- imipenem
- iohexol
- iopamidol
- isoniazid
- ketorolac
- leuprolide
- levocarnitine
- levofloxacin
- lidocaine
- lidocaine topical
- linezolid
- lisdexamfetamine
- lisocabtagene maraleucel
- lithium
- lorlatinib
- magnesium citrate
- mefloquine
- meropenem
- methamphetamine
- methotrexate
- methoxy polyethylene glycol-epoetin beta
- methylphenidate
- metronidazole
- mexiletine
- moxifloxacin
- nafarelin
- nafcillin
- ofloxacin
- oxacillin
- penicillin G
- penicillin V
- phendimetrazine
- phentermine
- piperacillin
- polyethylene glycol
- polyethylene glycol/electrolytes
- pyridostigmine
- pyrimethamine
- quinine
- rifampin
- rivastigmine
- sodium phosphate (bowel prep)
- sodium picosulfate
- sulfate bowel prep
- tacrolimus
- teclistamab
- terbutaline
- theophylline
- tisagenlecleucel
- tranexamic acid
- triamcinolone
- triptorelin
- valacyclovir
- valganciclovir
- varenicline
Adverse Reactions .
Serious Reactions
- respiratory depression
- apnea
- respiratory failure
- dependency
- abuse
- seizures
- suicidality
- tachycardia
- hypotension, severe
- syncope
- hypersensitivity rxn
- leukopenia
- agranulocytosis
- pancytopenia
- thrombocytopenia
- CNS stimulation, paradoxical
- withdrawal sx if abrupt D/C
- protracted withdrawal syndrome
- behavioral changes or cognitive deficits (>3h use in pts <3 yo)
- behavioral changes or cognitive deficits (repeat sedation use in pts <3 yo)
Common Reactions
- sedation
- dizziness
- asthenia
- ataxia
- local injection site rxn
- respiratory depression
- hypoventilation (IM or IV use)
- hypotension
- fatigue
- amnesia
- confusion
- disinhibition
- irritability
- libido changes
- menstrual irregularities
- diplopia
- dysarthria
- appetite changes
- constipation
- incontinence
- urinary retention
- extrapyramidal sx
- ALT or AST elevated
- LDH elevated
Safety/Monitoring .
Monitoring Parameters
resp. fxn if given IV; CBC, LFTs if prolonged tx
Benzyl Alcohol Content
avoid use of IM/IV forms in neonates; serious, potentially fatal gasping syndrome may occur
Propylene Glycol Content
IM/IV forms contain propylene glycol; CNS toxicity (incl. seizures/IVH), unresponsiveness, tachypnea, tachycardia, diaphoresis, lactic acidosis, hyperosmolality, hypotension may occur, esp. in neonates/infants/children or in renal impairment
Polyethylene Glycol Content
IM/IV forms contain polyethylene glycol; acute tubular necrosis may occur, especially in renal impairment and at higher than recommended doses
Look/Sound-Alike Drug Names
Ativan confused with: ALPRAZolam; Ambien; Antivert; Artane; Atarax; clonazePAM
LORazepam confused with: ALPRAZolam; cloBAZam; clonazePAM; diazePAM; loperamide; loratadine; midazolam; oxazepam; temazepam; zolpidem
Pregnancy/Lactation .
Pregnancy
Clinical Summary
weigh risk/benefit during pregnancy, esp. in 3rd trimester if prolonged (>3h) or repeated admin. for sedation use; possible risk of teratogenicity based on conflicting human data w/ benzodiazepine class; risk of neonatal respiratory depression, hypotonia, sedation, and withdrawal sx w/ near term use based on human data w/ benzodiazepine class; possible risk of adverse neurodevelopmental outcomes based on animal data w/ other sedatives
Pregnancy Registry
encourage pts to enroll in National Pregnancy Registry for Psychiatric Medications at 1-866-961-2388 or www.womensmentalhealth.org/pregnancyregistry
Lactation
Clinical Summary
may use low doses short-term while breastfeeding, otherwise monitor infant closely; no known risk of infant harm based on limited human data, though possible risk of infant CNS depression based on limited human data w/ other benzodiazepines and drug properties; no human data available to assess effects on milk production
Pharmacology .
Metabolism: liver; CYP450: unknown
Excretion: urine; Half-life: 12h (PO form), 14h (INJ form)
Subclass: Antiemetics, Benzodiazepines ; Benzodiazepines (BZDs), Intermediate-acting ; Dependence: Alcohol ; Insomnia ; Sedation ; Seizure Disorders ; Toxicity: Drugs
Mechanism of Action
binds to benzodiazepine receptors; enhances GABA effects
Formulary .
No Formulary Selected
Manufacturer/Pricing .
Manufacturer: Bausch Health Companies Inc. (PO forms) and Hikma Pharmaceuticals USA Inc. (INJ form)
DEA/FDA: Schedule IV
Approximate Retail Price
from http://www.goodrx.com/ativan
oral tablet:
- 0.5 mg (30 ea): $890.00
- 1 mg (10 ea): $402.00
- 2 mg (30 ea): $1,884.00
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