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Lorazepam

Class: Benzodiazepines
VA Class: CN302
CAS Number: 846-49-1
Brands: Ativan

Medically reviewed by Drugs.com on Mar 3, 2022. Written by ASHP.

Warning

Special Alerts:

A standardized concentration for this drug has been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. The drug is included in a standard concentration list which may apply to an IV or oral compounded liquid formulation. For additional information, see the ASHP website [Web].

[Posted 09/23/2020]

TOPIC: Benzodiazepine Drug Class: Drug Safety Communication - Boxed Warning Updated to Improve Safe Use

AUDIENCE: Patient, Health Professional, Pharmacy

ISSUE: The FDA is requiring the Boxed Warning, FDA's most prominent warning, be updated by adding other information to the prescribing information for all benzodiazepine medicines. This information will describe the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions consistently across all the medicines in the class. The FDA is also requiring updates to the existing patient Medication Guides to help educate patients and caregivers about these risks.

Other changes are also being required to several sections of the prescribing information, including to the Warnings and Precautions, Drug Abuse and Dependence, and Patient Counseling Information sections.

BACKGROUND: Benzodiazepines are a class of medicines approved to treat generalized anxiety disorder, insomnia, seizures, social phobia, and panic disorder.

RECOMMENDATION:

Health Care Professionals

  • Consider the patient's condition and the other medicines being taken, and assess the risk of abuse, misuse, and addiction, available at: [Web].

  • Limit the dosage and duration of each medicine to the minimum needed to achieve the desired clinical effect when prescribing benzodiazepines, alone or in combination with other medicines.

  • Use a gradual taper to reduce the dosage or to discontinue benzodiazepines to reduce the risk of acute withdrawal reactions.

  • Take precautions when benzodiazepines are used in combination with opioid addiction medications, available at: [Web].

Patients, Parents, and Caregivers

  • Always tell your health care professionals about all the prescription and over-the-counter (OTC) medicines you are taking or any other substances you are using, including alcohol.

  • Take benzodiazepines and all medicines exactly as prescribed by your health care professional

  • Discuss a plan for slowly decreasing the dose and frequency of your benzodiazepine(s) with your health care professional.

  • Contact your health care professional if you experience withdrawal symptoms or your medical condition worsens.

  • Go to an emergency room or call 911 if you have trouble breathing or other serious side effects such as seizures.

For more information visit the FDA website at: [Web] and [Web].

Warning

    Concomitant Use with Opiates
  • Concomitant use of benzodiazepines and opiates may result in profound sedation, respiratory depression, coma, and death.

  • Reserve concomitant use for patients in whom alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy and monitor closely for respiratory depression and sedation. (See Specific Drugs under Interactions.)

Introduction

Benzodiazepine; anticonvulsant, anxiolytic, and sedative.

Uses for Lorazepam

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

Anxiety Disorders

Management of anxiety disorders and short-term relief of anxiety or anxiety associated with depressive symptoms.

Preoperative Sedation, Anxiolysis, and Amnesia

Used preoperatively to produce sedation, anxiolysis, and anterograde amnesia.

Particularly useful when relief of anxiety and diminished recall of events associated with the surgical procedure are desired.

Status Epilepticus

Treatment of status epilepticus.

Benzodiazepines are considered initial drugs of choice for management of status epilepticus because of their rapid onset of action, demonstrated efficacy, safety, and tolerability. Evidence supports use of IV lorazepam, IV diazepam, or IM midazolam. Individualize choice of therapy based on local availability, route of administration, pharmacokinetics, cost, and other factors (e.g., treatment setting).

Sedation in Critical Care Settings

Has been used for sedation of intubated and mechanically ventilated patients in critical care settings (e.g., ICU).

Nonbenzodiazepine sedatives (dexmedetomidine or propofol) are generally preferred to benzodiazepines in mechanically ventilated, critically ill adults because of some modest clinical benefits that have been demonstrated (e.g., reduced duration of mechanical ventilation, shorter time to extubation, reduced risk of delirium).

When selecting an appropriate sedative agent, consider patient's individual sedation goals in addition to specific drug-related (e.g., pharmacology, pharmacokinetics, adverse effects, availability, cost) and patient-related (e.g., comorbid conditions such as anxiety, seizures, or alcohol or benzodiazepine withdrawal) factors.

Schizophrenia

Has been used in management of schizophrenia; may be helpful for management of anxiety, agitation, and sleep disturbances that are often present during the acute phase of schizophrenia in patients receiving antipsychotic therapy.

May be helpful in patients experiencing akathisia while receiving antipsychotic drugs (e.g., for management of schizophrenia).

Also has been used for treatment of acute catatonic reactions, whether associated with schizophrenia or other conditions.

Cancer Chemotherapy-induced Nausea and Vomiting

Alone or as adjunctive therapy for the management of nausea and vomiting associated with emetogenic cancer chemotherapy (including cisplatin).

Delirium

Management of delirium alone or in combination with an antipsychotic agent (e.g., haloperidol).

Drug-induced Cardiovascular Emergencies

Adjunct in the management of certain drug-induced cardiovascular emergencies. May be beneficial adjunctively in patients with cocaine-induced acute coronary syndrome.

Lorazepam Dosage and Administration

General

  • Use smallest effective dosage to avoid oversedation.

  • In patients who have received prolonged (e.g., for several months) therapy, avoid abrupt discontinuance, since manifestations of withdrawal can be precipitated; gradually taper dosage.

Administration

Administer orally, IM, or by IV injection or IV infusion. Avoid intra-arterial injection (arteriospasm may cause gangrene, possibly requiring amputation).

Oral Administration

Mix oral concentrate solution with a liquid (e.g., water, juice, carbonated or soda-like beverage) or semi-solid food (e.g., applesauce, pudding). Use the calibrated dropper provided by manufacturer. Stir liquid or food mixture gently for a few seconds and then consume immediately; do not store mixture for future use.

IM Administration

Administer undiluted and inject deep into the muscle mass. IM administration usually not recommended in the treatment of status epilepticus, but may be used if IV access not available.

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Must dilute prior to IV administration. (See Dilution under Dosage and Administration.)

Administer by direct IV injection or into tubing of an existing IV infusion. (See Solution Compatibility under Stability.)

Direct injection should be made with repeated aspiration to ensure that none of the drug is injected intra-arterially and that perivascular extravasation does not occur. If pain occurs during injection, immediately stop administration and determine whether intra-arterial injection or extravasation has occurred.

Equipment necessary to maintain a patent airway and to support respiration and ventilation should be immediately available prior to IV administration. Monitor vital signs during IV infusion of the drug.

Dilution

For administration as a direct IV injection, dilute commercially available injection with an equal volume of compatible diluent (e.g., sterile water for injection, 0.9% sodium chloride injection, or 5% dextrose injection) immediately prior to IV administration.

Following dilution, mix solution thoroughly by gently inverting container repeatedly until a homogenous solution is obtained; do not shake vigorously.

Rate of Administration

Administer IV injection slowly at a rate not exceeding 2 mg/minute.

Dosage

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

Pediatric Patients

Status Epilepticus†
IV

Doses of 0.05–0.1 mg/kg have been used.

Sedation in Critical Care Settings†
IV

Children ≥2 months of age: Some clinicians have suggested intermittent IV infusions of 0.025–0.05 mg/kg (up to 2 mg as initial dose) every 2–4 hours. Alternatively, a continuous IV infusion at a rate of 0.025 mg/kg per hour (up to 2 mg/hour) has been given with supplemental injections as needed to provide the desired level of sedation. Reduce initial dose by 50% in children <2 months of age because of wide interpatient variations in dosage requirements and low hepatic metabolic function.

Adults

Anxiety
Oral

Initially, 2–3 mg daily divided in 2 or 3 doses. Maintenance dosage of 1–10 mg daily (usually 2–6 mg) in divided doses, with the largest dose administered at bedtime. Increase dosage gradually if higher dosage is indicated; increase the evening dose before the daytime doses.

For insomnia caused by anxiety or transient situational stress, 2–4 mg as a single daily dose, usually at bedtime.

Preoperative Sedation, Anxiolysis, and Amnesia
IM

0.05 mg/kg (up to 4 mg) at least 2 hours prior to surgery.

IV

Initially, 0.044 mg/kg (or total of 2 mg, whichever is smaller) 15–20 minutes prior to surgery; do not routinely exceed this dosage in patients >50 years of age. For amnestic effects, doses up to 0.05 mg/kg (maximum 4 mg) may be administered.

Status Epilepticus
IV

Initially, 4 mg. If seizures continue or recur after a 10- to 15-minute observation period, administer an additional 4-mg dose. Manufacturer states that experience with administration of additional doses is limited.

Sedation in Critical Care Settings†
IV

Some experts recommend loading dose of 0.02–0.04 mg/kg (up to 2 mg), followed by intermittent injections of 0.02–0.06 mg/kg every 2–6 hours as needed or a continuous IV infusion at a rate of 0.01–0.1 mg/kg per hour (not to exceed 10 mg/hour).

Cancer Chemotherapy-induced Nausea and Vomiting†
Oral

2.5 mg the evening before and just after initiation of chemotherapy.

IV

1.5 mg/m2 (up to 3 mg) over 5 minutes, given 45 minutes before administration of chemotherapy.

Delirium†
IV

0.5–1 mg, immediately following 3 mg of haloperidol.

Prescribing Limits

Adults

Preoperative Sedation, Anxiolysis, and Amnesia
IM

Manufacturer recommends maximum dose of 4 mg.

IV

Manufacturer states initial dose of up to 2 mg usually administered for sedation and relief of anxiety. Doses up to 4 mg may be administered for amnestic effects.

Status Epilepticus
IV

Manufacturer states experience with doses beyond the usual (4 mg initially, followed by an additional 4-mg dose 10–15 minutes later if seizures continue or recur) very limited.

Sedation in Critical Care Settings†
IV

Some experts recommend that IV loading doses not exceed 2 mg.

If a continuous IV infusion is used, some experts recommend that the infusion be administered no faster than 10 mg/hour.

Special Populations

Hepatic Impairment

Dosage adjustments not required for parenteral administration.

Adjust oral dosage carefully in patients with severe hepatic insufficiency because oral therapy may exacerbate hepatic encephalopathy; lower than recommended dosages may be sufficient in these patients.

Renal Impairment

Dosage adjustment not required for single doses of lorazepam injection; however, exercise caution with administration of multiple doses over a short period of time.

Geriatric Patients

Cautious dosage selection recommended because of greater sensitivity and possible age-related decreases in hepatic or renal function; initiate therapy at the lower end of the usual range.

Anxiety Disorders

Oral: Initially, 1–2 mg daily divided in 2 or 3 doses.

Preoperative Sedation, Anxiolysis, and Amnesia

Patients >50 years of age generally should not receive initial IV dose >2 mg. Excessive and prolonged sedation may occur.

Cautions for Lorazepam

Contraindications

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

  • Known hypersensitivity to benzodiazepines or any ingredient in the formulation (e.g., benzyl alcohol, polyethylene glycol, or propylene glycol in the injection).

  • Acute angle-closure glaucoma (but may be administered to patients with open-angle glaucoma who are receiving appropriate therapy); however, clinical rationale for this contraindication has been questioned.

  • Injection also contraindicated in patients with sleep apnea, patients with severe respiratory insufficiency (except in those requiring relief of anxiety and/or diminished recall of events while receiving mechanical ventilation), and in premature infants (because the formulation contains benzyl alcohol).

  • Do not administer injection intra-arterially.

Warnings/Precautions

Warnings

Concomitant Use with Opiates

Concomitant use of benzodiazepines, including lorazepam, and opiates may result in profound sedation, respiratory depression, coma, and death. (See Boxed Warning.) Substantial proportion of fatal opiate overdoses involve concurrent benzodiazepine use.

Reserve concomitant use of lorazepam and opiates for patients in whom alternative treatment options are inadequate. (See Specific Drugs under Interactions.)

Respiratory and Cardiovascular Effects

Use oral lorazepam with caution in patients with compromised respiratory function (e.g., COPD, sleep apnea).

Possible apnea, hypotension, bradycardia, or cardiac arrest with parenteral administration, particularly in geriatric or severely ill patients, in patients with limited pulmonary reserve or unstable cardiovascular status, or if the drug is administered IV too rapidly.

Concomitant use of other CNS depressants may increase the risk of apnea.

Administer IV only in settings in which continuous monitoring of respiratory and cardiac function (i.e., pulse oximetry) is possible. Monitoring of vital signs should continue during recovery period.

Facilities, age- and size-appropriate equipment for bag/mask/valve ventilation and intubation, drugs, and skilled personnel necessary for ventilation and intubation, administration of oxygen, assisted or controlled respiration, airway management, and cardiovascular support should be immediately available when lorazepam is administered IV.

Status Epilepticus

Should be used for the treatment of status epilepticus only by clinicians experienced in the comprehensive management of the disease.

Careful monitoring of respiratory rate and maintenance of an adequate, patent airway is required; ventilatory support may be necessary.

Because of the prolonged duration of action, sedative effects of lorazepam (especially after multiple doses) may increase impairment of consciousness observed in the postictal state.

CNS Effects

Performance of activities requiring mental alertness and physical coordination (operating machinery, driving a motor vehicle) may be impaired. Impairment may persist for 24–48 hours following parenteral administration. Premature ambulation may result in falls.

Concurrent use of other CNS depressants may cause additive or potentiated CNS depression. (See Concomitant Use with Opiates under Cautions and also see Specific Drugs under Interactions.)

May interfere with assessment of level of anesthesia when administered IV prior to regional or local anesthesia, especially when given at doses >0.05 mg/kg or when opiate agonists or partial agonists are used concomitantly with recommended lorazepam doses.

Psychiatric Indications

Do not use in patients with primary depressive disorder or psychosis.

Abuse Potential

Possible tolerance, psychologic dependence, and physical dependence following prolonged administration.

Patients with a history of drug or alcohol dependence or abuse are at risk of habituation or dependence; use only with careful surveillance in such patients.

Withdrawal

Symptoms of withdrawal (similar to barbiturates or alcohol) may occur if discontinued abruptly. Avoid abrupt discontinuance; gradually taper dosage following extended therapy.

Endoscopic Procedures

Insufficient data to support use for outpatient endoscopic procedures; when used for inpatient endoscopic procedures, adequate recovery room observation time required.

General Precautions

Suicide

Possibility of suicide in depressed patients; do not use in such patients without adequate antidepressant therapy.

Paradoxical Reactions

Paradoxical reactions (e.g., anxiety, excitation, hostility, aggression, rage, sleep disturbances/insomnia, sexual arousal, hallucinations) may occur, particularly in children and geriatric patients. Discontinue drug if such reactions occur.

Propylene Glycol or Polyethylene Glycol Toxicity

Possible adverse effects associated with propylene glycol (e.g., lactic acidosis, hyperosmolality, hypotension) or polyethylene glycol (e.g., acute tubular necrosis) in patients receiving higher than recommended parenteral dosages. More likely to occur in patients with renal impairment.

Specific Populations

Pregnancy

Category D.

Based on animal data, repeated or prolonged use of general anesthetics and sedation drugs, including lorazepam, during the third trimester of pregnancy may result in adverse neurodevelopmental effects in the fetus. (See Pediatric Use under Cautions and also see Advice to Patients.)

Lactation

Distributed into milk.

Administer orally to nursing women only if the potential benefits to the woman outweigh the possible risk to the infant. Monitor nursing infants for adverse effects (e.g., sedation, irritability).

Do not administer lorazepam injection to nursing women because of possible adverse effects to the infant (e.g., sedation).

Pediatric Use

Safety and efficacy of tablets and oral concentrate solution not established in children <12 years of age.

Safety of the injection for treatment of status epilepticus or efficacy for preoperative sedation not established in children <18 years of age.

Paradoxical excitation (e.g., tremors, agitation, euphoria, logorrhea, brief episodes of visual hallucinations) reported in 10–30% of children <8 years of age.

Seizures and myoclonus reported in pediatric patients, especially low birth weight neonates, receiving lorazepam injection. Brief tonic-clonic seizures reported in children receiving lorazepam for the management of atypical petit mal status epilepticus.

Repeated or prolonged use of general anesthetics and sedation drugs, including lorazepam, in children <3 years of age or during the third trimester of pregnancy may adversely affect neurodevelopment. In animals, use for >3 hours of anesthetic and sedation drugs that block N-methyl-d-aspartic acid (NMDA) receptors and/or potentiate GABA activity leads to widespread neuronal apoptosis in the brain and long-term deficits in cognition and behavior; clinical relevance to humans is unknown. Some evidence suggests similar deficits may occur in children following repeated or prolonged exposure to anesthesia early in life. Some evidence also indicates that a single, relatively brief exposure to general anesthesia in generally healthy children is unlikely to cause clinically detectable deficits in global cognitive function or serious behavioral disorders. Most studies to date have substantial limitations; further research needed to fully characterize effects, particularly for prolonged or repeated exposures and in more vulnerable populations (e.g., less healthy children). Consider benefits and potential risks when determining the timing of elective procedures requiring anesthesia. FDA states that medically necessary procedures should not be delayed or avoided. (See Advice to Patients.)

Some pediatric patients (premature and low-birth weight infants or those receiving high doses of lorazepam injection) may be susceptible to adverse effects associated with benzyl alcohol, polyethylene glycol, and propylene glycol. Large amounts of benzyl alcohol (i.e., 100–400 mg/kg daily) have been associated with toxicity in neonates. (See Propylene Glycol or Polyethylene Glycol Toxicity under Cautions.)

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults. Possibility of greater sensitivity to the drug (e.g., respiratory or CNS depression. sedation) in some geriatric individuals.

Select initial dosages at the lower end of the usual range because of potential for greater sensitivity and age-related decreases in hepatic or renal function. (See Geriatric Patients under Dosage and Administration.)

May cause excessive sedation for 6–8 hours or longer after surgery in this population.

Possible paradoxical excitation (e.g., anxiety, excitation, hostility, aggression, rage, sleep disturbances/insomnia, sexual arousal, hallucinations).

Hepatic Impairment

Lorazepam injection is not recommended for use in patients with hepatic failure; use with caution in patients with mild to moderate hepatic disease. (See Hepatic Impairment under Dosage and Administration.)

Oral lorazepam may exacerbate hepatic encephalopathy; therefore, use with caution in patients with severe hepatic insufficiency and/or encephalopathy.

Renal Impairment

Lorazepam injection is not recommended for use in patients with renal failure; use with caution in patients with mild to moderate renal disease. (See Renal Impairment under Dosage and Administration.)

Common Adverse Effects

With oral therapy, sedation, dizziness, weakness, unsteadiness.

With parenteral therapy for the management of status epilepticus, hypotension, somnolence, respiratory failure; with parenteral therapy for preoperative use, excessive sleepiness, drowsiness.

With IM injections, local effects (e.g., pain, sensation of burning, redness) observed at the injection site.

Interactions for Lorazepam

Specific Drugs

Drug

Interaction

Comments

Cimetidine

No effect on lorazepam pharmacokinetics

No dosage adjustment of lorazepam required

Clozapine

Marked sedation, excessive salivation, ataxia, hypotension, delirium, respiratory arrest, and, rarely, death reported

Use concomitantly with caution

CNS depressants (e.g., barbiturates, sedatives, anticonvulsants, alcohol)

Additive CNS effects

Use concomitantly with caution

Avoid alcohol use

Contraceptives, oral

Increased clearance of parenteral lorazepam observed

Dosage of parenteral lorazepam may need to be increased

Disulfiram

No effect on lorazepam pharmacokinetics

Haloperidol

Apnea, coma, bradycardia, arrhythmia, cardiac arrest, and death reported

Use concomitantly with caution

Loxapine

Respiratory depression, stupor, and/or hypotension reported rarely

Use concomitantly with caution

Metoprolol

No effect on lorazepam pharmacokinetics

No dosage adjustment of lorazepam required

Metronidazole

No effect on lorazepam pharmacokinetics

No dosage adjustment of lorazepam required

Opiate agonists and partial agonists

Risk of profound sedation, respiratory depression, coma, or death

Whenever possible, avoid concomitant use

Opiate analgesics: Use concomitantly only if alternative treatment options are inadequate; use lowest effective dosages and shortest possible duration of concomitant therapy; monitor closely for respiratory depression and sedation

In patients receiving lorazepam, initiate opiate analgesic, if required, at reduced dosage and titrate based on clinical response

In patients receiving an opiate analgesic, initiate lorazepam, if required for any indication other than epilepsy, at lower dosage than indicated in the absence of opiate therapy and titrate based on clinical response

Opiate antitussives: Avoid concomitant use

Consider offering naloxone to patients receiving benzodiazepines and opiates concomitantly

Probenecid

Decreased clearance and increased half-life of lorazepam, possibly due to inhibition of glucuronidation

Reduce lorazepam dosage by 50%

Propranolol

No effect on lorazepam pharmacokinetics

No dosage adjustment of lorazepam required

Ranitidine

No effect on lorazepam pharmacokinetics

No dosage adjustment of lorazepam required

Scopolamine

Possible increased sedation, hallucinations, and irrational behavior

Use concomitantly with caution

Theophylline

Possible decreased sedative effects of lorazepam

Valproate

Decreased clearance and increased plasma concentration of lorazepam, possibly due to inhibition of glucuronidation

Reduce lorazepam dosage by 50%

Lorazepam Pharmacokinetics

Absorption

Bioavailability

Readily absorbed following oral administration; absolute bioavailability is 90%.

Completely and rapidly absorbed following IM administration.

Peak plasma concentrations are attained in approximately 2 hours following oral administration and within 3 hours following IM administration.

Onset

After IV administration, the onset of anticonvulsant, anxiolytic, or sedative action occurs in 1–5 minutes.

After IM administration, the onset of action is 15–30 minutes.

Duration

After IV or IM administration, the duration of anticonvulsant, anxiolytic, or sedative action is 12–24 hours.

Distribution

Extent

Widely distributed into body tissues; crosses the blood-brain barrier.

Crosses the placenta and is distributed into milk.

Plasma Protein Binding

Approximately 85–91%.

Elimination

Metabolism

Extensively metabolized in the liver to inactive metabolites.

Elimination Route

Excreted principally in urine as metabolites.

Half-life

10–20 hours.

Special Populations

In neonates, clearance reduced by 80% compared with healthy adults.

In geriatric patients or patients with hepatic cirrhosis, clearance not substantially altered.

In patients with renal impairment, clearance of lorazepam glucuronide is reduced, but total clearance of lorazepam is not altered following single IV dose.

Stability

Storage

Oral

Tablets

Tight containers at 25°C (may be exposed to 15–30°C).

Oral Concentrate Solution

2–8°C; protect from light.

Parenteral

Injection

2–8°C; protect from light.

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Variable

Dextrose 5% in water

Ringer’s injection, lactated

Sodium chloride 0.9%

Drug Compatibility
Admixture CompatibilityHID

Compatible

Levetiracetam

Incompatible

Dexamethasone sodium phosphate with diphenhydramine HCl

Y-Site CompatibilityHID

Compatible

Acetaminophen

Acyclovir sodium

Albumin human

Allopurinol sodium

Amifostine

Amikacin sulfate

Amiodarone HCl

Anakinra

Atracurium besylate

Bivalirudin

Bumetanide

Cangrelor tetrasodium

Caspofungin acetate

Cefotaxime sodium

Ceftaroline fosamil

Ceftolozane sulfate-tazobactam sodium

Ciprofloxacin

Cisatracurium besylate

Cladribine

Clonidine HCl

Co-trimoxazole

Dexamethasone sodium phosphate

Dexmedetomidine HCl

Diltiazem HCl

Dobutamine HCl

Docetaxel

Dopamine HCl

Doripenem

Doxorubicin HCl liposome injection

Epinephrine HCl

Erythromycin lactobionate

Etomidate

Etoposide phosphate

Famotidine

Fenoldopam mesylate

Fentanyl citrate

Filgrastim

Fluconazole

Fludarabine phosphate

Fosphenytoin sodium

Furosemide

Gemcitabine HCl

Gentamicin sulfate

Granisetron HCl

Haloperidol lactate

Heparin sodium

Hetastarch in lactated electrolyte injection (Hextend)

Hydrocortisone sodium succinate

Hydromorphone HCl

Isavuconazonium sulfate

Labetalol HCl

Levofloxacin

Linezolid

Melphalan HCl

Meropenem-vaborbactam

Methadone HCl

Metronidazole

Micafungin sodium

Midazolam HCl

Milrinone lactate

Morphine sulfate

Nicardipine HCl

Nitroglycerin

Norepinephrine bitartrate

Oritavancin diphosphate

Oxaliplatin

Paclitaxel

Palonosetron HCl

Pancuronium bromide

Pemetrexed disodium

Piperacillin sodium–tazobactam sodium

Plazomicin sulfate

Posaconazole

Potassium chloride

Propofol

Ranitidine HCl

Remifentanil HCl

Tacrolimus

Tedizolid phosphate

Teniposide

Thiotepa

Vancomycin HCl

Vecuronium bromide

Vinorelbine tartrate

Zidovudine

Incompatible

Aldesleukin

Aztreonam

Gallium nitrate

Idarubicin HCl

Imipenem–cilastatin sodium

Letermovir

Omeprazole sodium

Ondansetron HCl

Sargramostim

Variable

Foscarnet sodium

Actions

  • Effects appear to be mediated through the inhibitory neurotransmitter GABA; the site and mechanism of action within the CNS appear to involve a macromolecular complex (GABAA-receptor-chloride ionophore complex) that includes GABAA receptors, high-affinity benzodiazepine receptors, and chloride channels.

Advice to Patients

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

  • Provide manufacturer's patient information (e.g., medication guide) to the patient each time oral lorazepam preparations (tablets, solution concentrate) are dispensed.

  • Risk of potentially fatal additive effects (e.g., profound sedation, respiratory depression, coma) if used concomitantly with opiates either therapeutically or illicitly. Avoid concomitant use of opiate antitussives; also avoid concomitant use of opiate analgesics unless use is supervised by clinician.

  • Potential for drug to impair mental alertness or physical coordination; avoid driving or operating machinery until effects on individual are known. Following parenteral dose, wait 24–48 hours or until drowsiness subsides before participating in such activities.

  • Importance of informing patients of the pharmacologic effects of lorazepam (e.g., sedation, relief of anxiety, lack of recall) and the duration of these effects (≥8 hours) so that they may understand the risks and benefits.

  • Importance of avoiding premature ambulation (within 8 hours of dose) in patients receiving parenteral lorazepam.

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs. Importance of avoiding alcohol-containing beverages or products (for at least 24–48 hours after parenteral administration).

  • When procedures requiring general anesthetics or sedation drugs, including lorazepam, are considered for young children or pregnant women, importance of discussing with the patient, parent, or caregiver the benefits, risks (including potential risk of adverse neurodevelopmental effects), and appropriate timing and duration of the procedure.

  • Importance of informing clinicians about any concomitant illnesses (e.g., depression, respiratory disorders).

  • Importance of taking only as prescribed; do not increase dosage or duration of therapy unless otherwise instructed by a clinician.

  • Importance of not abruptly discontinuing therapy; consult clinician about discontinuing use.

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Lorazepam is subject to control under the Federal Controlled Substances Act of 1970 as a schedule IV (C-IV) drug.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

LORazepam

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

For solution, concentrate

2 mg/mL*

LORazepam Solution Concentrate (C-IV)

Tablets

0.5 mg*

Ativan (C-IV)

Valeant

LORazepam Tablets (C-IV)

1 mg*

Ativan (C-IV; scored)

Valeant

LORazepam Tablets (C-IV)

2 mg*

Ativan (C-IV; scored)

Valeant

LORazepam Tablets (C-IV)

Parenteral

Injection

2 mg/mL*

Ativan (C-IV)

West-Ward

LORazepam Injection (C-IV)

4 mg/mL*

Ativan (C-IV)

West-Ward

LORazepam Injection (C-IV)

AHFS DI Essentials™. © Copyright 2022, Selected Revisions March 3, 2022. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

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