Lorazepam
Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety, insomnia, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting. It is also used during surgery to interfere with memory formation, to sedate those who are being mechanically ventilated, and, along with other treatments, for acute coronary syndrome due to cocaine use. It can be given orally, transdermally, intravenously, or intramuscularly. When given by injection, onset of effects is between one and thirty minutes and effects last for up to a day.
Common side effects include weakness, sleepiness, dizziness, decreased alertness, decreased memory formation, low blood pressure, and a decreased effort to breathe. When given intravenously, the person is typically closely monitored. Among those who are depressed, there may be an increased risk of suicide. With long-term use, tolerance may develop, with larger doses required for the same effect. Physical dependence and psychological dependence may also occur. If stopped suddenly after long-term use, benzodiazepine withdrawal syndrome may occur. Older people more often develop adverse effects. In this age group, lorazepam is associated with falls and hip fractures. Due to these concerns, lorazepam use is generally recommended for up to four weeks.
Lorazepam was initially patented in 1963 and went on sale in the United States in 1977. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. In 2023, it was the 100th most commonly prescribed medication in the United States, with more than 6million prescriptions.
Medical uses
Anxiety
Lorazepam is used in the short-term management of severe anxiety. In the US, the Food and Drug Administration advises against use of benzodiazepines such as lorazepam for longer than four weeks. It is fast-acting, and useful in treating fast-onset anxiety and panic attacks.Lorazepam can effectively reduce agitation and induce sleep, and the duration of effects from a single dose makes it an appropriate choice for the short-term treatment of insomnia, especially in the presence of severe anxiety or night terrors. It has a fairly short duration of action.
Withdrawal symptoms, including rebound insomnia and rebound anxiety, may occur after seven days of use of lorazepam.
Seizures
Intravenous diazepam or lorazepam are first-line treatments for convulsive status epilepticus. Lorazepam is more effective than diazepam and intravenous phenytoin in the treatment of status epilepticus and has a lower risk of continuing seizures that might require additional medication. However, phenobarbital has a superior success rate compared to lorazepam and other drugs, at least in the elderly.Lorazepam's anticonvulsant properties and pharmacokinetic profile make intravenous use reliable for terminating acute seizures, but induce prolonged sedation. Orally administered benzodiazepines, including lorazepam, are occasionally used as long-term prophylactic treatment of resistant absence seizures; because of gradual tolerance to their anti-seizure effects, benzodiazepines are not considered first-line therapies. Additionally, common seizure characteristics pose some difficulties with regard to oral administration.
Lorazepam's anticonvulsant and central nervous system depressant properties are useful for the treatment and prevention of alcohol withdrawal syndrome. In this setting, impaired liver function is not a hazard with lorazepam, since lorazepam does not require oxidation, in the liver or otherwise, for its metabolism. Lorazepam is noted as being the most tolerable benzodiazepine in those with advanced-stage liver disease.
Sedation
The relative effectiveness of lorazepam in preventing new memory formation, along with its ability to reduce agitation and anxiety, makes it useful as premedication. It is given before a general anesthetic to reduce the amount of anesthetic required or before unpleasant awake procedures, such as in dentistry or endoscopies, to reduce anxiety, increase compliance, and induce anterograde amnesia for the procedure. Orally administered lorazepam is given 90 to 120 minutes before procedures, and intravenous lorazepam is given up to 10 minutes before procedures. Lorazepam is sometimes used as an alternative to midazolam in palliative sedation. In intensive care units, lorazepam is sometimes used to produce anxiolysis, hypnosis, and amnesia.Lorazepam is sometimes used for individuals receiving mechanical ventilation. In critically ill people, propofol has been found to be superior to lorazepam both in effectiveness and overall cost; as a result, the use of propofol for this indication is now encouraged, whereas the use of lorazepam is discouraged.
Agitation
Lorazepam is sometimes used as an alternative to haloperidol when there is the need for rapid sedation of violent or agitated individuals. Haloperidol plus promethazine is preferred due to better effectiveness and due to lorazepam's adverse effects on respiratory function. Adverse effects such as behavioral disinhibition may make benzodiazepines inappropriate for some people who are acutely psychotic. Acute delirium is sometimes treated with lorazepam, but as it can cause paradoxical effects, it is preferably given together with haloperidol. Lorazepam is absorbed relatively slowly if given intramuscularly, a common route in restraint situations.Other
with inability to speak is responsive to lorazepam. Symptoms may recur and treatment for some days may be necessary. Catatonia due to abrupt or overly rapid withdrawal from benzodiazepines, as part of the benzodiazepine withdrawal syndrome, also responds to lorazepam treatment. As lorazepam can have paradoxical effects, haloperidol is sometimes given at the same time.It is sometimes used in chemotherapy in addition to antiemetics. A transdermal product known as ABH gel containing lorazepam along with diphenhydramine and haloperidol is widely used in hospice and palliative care settings for the treatment of nausea and vomiting, though studies suggest absorption of the active ingredients is poor via this route, and evidence for efficacy is limited.
Available forms
Pure lorazepam is an almost white powder that is nearly insoluble in water and oil. In medicinal form, it is mainly available as tablets and a solution for injection, but, in some locations, it is also available as a skin patch, an oral solution, and a sublingual tablet.Lorazepam injectable solution is administered either by deep intramuscular injection or by intravenous injection. The injectable solution comes in 1 mL ampoules containing 2 or 4 mg of lorazepam. The solvents used are polyethylene glycol 400 and propylene glycol. As a preservative, the injectable solution contains benzyl alcohol. Toxicity from propylene glycol has been reported in the case of a person receiving a continuous lorazepam infusion.
Topical formulations of lorazepam, while sometimes used as a treatment for nausea, especially in people in hospice, has been advised against by the American Academy of Hospice and Palliative Medicine for this purpose as it has not been proven effective.
Adverse effects
Many beneficial effects of lorazepam may become adverse effects when unwanted. Adverse effects can include sedation and low blood pressure; the effects of lorazepam are increased in combination with other CNS depressants. Other adverse effects include confusion, ataxia, inhibiting the formation of new memories, pupil constriction, and hangover effects. With long-term benzodiazepine use, it is unclear whether cognitive impairments fully return to normal after stopping lorazepam use; cognitive deficits persist for at least six months after withdrawal, but longer than six months may be required for recovery of cognitive function. Lorazepam appears to have more profound adverse effects on memory than other benzodiazepines; it impairs both explicit and implicit memory. In the elderly, falls may occur as a result of benzodiazepines. Adverse effects are more common in the elderly, and they appear at lower doses than in younger people. Benzodiazepines can cause or worsen depression. Paradoxical effects can also occur, such as worsening of seizures, or paradoxical excitement; paradoxical excitement is more likely to occur in the elderly, children, those with a history of alcohol abuse, and in people with a history of aggression or anger problems. Lorazepam's effects are dose-dependent, meaning the higher the dose, the stronger the effects will be. Using the smallest dose needed to achieve desired effects lessens the risk of adverse effects. Sedative drugs and sleeping pills, including lorazepam, have been associated with an increased risk of death.Sedation is the side effect people taking lorazepam most frequently report. In a group of around 3,500 people treated for anxiety, the most common side effects complained of from lorazepam were sedation, dizziness, weakness, and unsteadiness. Side effects such as sedation and unsteadiness increased with age. Cognitive impairment, behavioral disinhibition and respiratory depression as well as hypotension may also occur.
- Paradoxical effects: In some cases, paradoxical effects can occur with benzodiazepines, such as increased hostility, aggression, angry outbursts, and psychomotor agitation. These effects are seen more commonly with lorazepam than with other benzodiazepines. Paradoxical effects are more likely to occur with higher doses, in people with pre-existing personality disorders and those with a psychiatric illness. Frustrating stimuli may trigger such reactions, though the drug may have been prescribed to help the person cope with such stress and frustration in the first place. As paradoxical effects appear to be dose-related, they usually subside on dose reduction or on complete withdrawal of lorazepam.
- Suicidality: Benzodiazepines are associated with an increased risk of suicide, possibly due to disinhibition. Higher dosages appear to confer greater risk.
- Amnesic effects: Among benzodiazepines, lorazepam has relatively strong amnesic effects, but people soon develop tolerance to this with regular use. An initial total daily lorazepam dose that does not exceed 2 mg may help avoid amnesia being a problem. This also applies to use for night sedation. Five participants in a sleep study were prescribed lorazepam 4 mg at night, and the next evening, three subjects unexpectedly volunteered memory gaps for parts of that day, an effect that subsided completely after two to three days' use. Amnesic effects cannot be estimated from the degree of sedation present, since the two effects are unrelated.
- High-dose or prolonged parenterally-administered lorazepam with its associated solvent can cause propylene glycol intoxication and poisoning.