lorazepam

(lor a' ze pam)

Apo-Lorazepam (CAN), Ativan, Novo-Lorazem (CAN), Nu-Loraz (CAN)

Pregnancy Category D
Controlled Substance C-IV

Drug classes
Benzodiazepine
Anxiolytic
Sedative-hypnotic

Therapeutic actions
Exact mechanisms are not understood; acts mainly at subcortical levels of the CNS,
leaving the cortex relatively unaffected. Main sites of action may be the limbic system
and reticular formation; benzodiazepines potentiate the effects of GABA, an inhibitory
neurotransmitter; anxiolytic effects occur at doses well below those necessary to cause
sedation and ataxia.

Indications
• Oral: Management of anxiety disorders or for short-term relief of symptoms of
anxiety or anxiety associated with depression
• Parenteral: Preanesthetic medication in adults to produce sedation, relieve anxiety,
and decrease recall of events related to surgery (parenteral)
• Unlabeled parenteral use: Management of status epilepticus, chemotherapy-
induced nausea and vomiting, acute alcohol withdrawal

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines, propylene glycol,
polyethylene glycol or benzyl alcohol (parenteral lorazepam); psychoses; acute
narrow-angle glaucoma; shock; coma; acute alcoholic intoxication with
depression of vital signs; pregnancy (crosses placenta; risk of congenital
malformations and neonatal withdrawal syndrome); labor and delivery ("floppy
infant" syndrome); and lactation.
• Use cautiously with impaired liver or kidney function.

Available forms
Injection—2, 4 mg/mL; oral solution—2 mg/mL; tablets—0.5, 1, 2 mg

Dosages
ADULTS
Oral
Usual dose is 2–6 mg/day; range 1–10 mg/day given in divided doses with largest dose
hs.
• Insomnia due to transient stress: 2–4 mg given hs.
IM
0.05 mg/kg up to a maximum of 4 mg administered at least 2 hr before operative
procedure.
IV
Initial dose is 2 mg total or 0.044 mg/kg, whichever is smaller. Do not exceed this dose in
patients older than 50 yr. Doses as high as 0.05 mg/kg up to a total of 4 mg may be given
15–20 min before the procedure to those benefited by a greater lack of recall. Continuous
infusion 0.5–1 mg/hr titrated, based on patient response.
PEDIATRIC PATIENTS
Drug should not be used in children < 12 yr.
GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC DISEASE
Initially, 1 to 2 mg/day in divided doses. Adjust as needed and tolerated.

Pharmacokinetics
Route Onset Peak Duration
Oral Intermediate 1–6 hr 12–24 hr
IM 15–30 min 60–90 min 12–24 hr
IV 1–5 min 10–15 min 12–24 hr

Metabolism: Hepatic; T1/2: 10–20 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

IV facts
Preparation: Dilute lorazepam immediately prior to IV use. For direct IV injection or
injection into IV line, dilute with an equal volume of compatible solution (sterile water
for injection, sodium chloride injection, or 5% dextrose injection); do not use if solution
is discolored or contains a precipitate. Protect from light.
Infusion: Direct inject slowly, or infuse at maximum rate of 2 mg/min.
Y-site incompatibilities: Do not mix with foscarnet, ondansetron.

Adverse effects
• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy,
fatigue, light-headedness, disorientation, anger, hostility, episodes of mania and
hypomania, restlessness, confusion, crying, delirium, headache, slurred speech,
dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness,
difficulty concentrating, vivid dreams, psychomotor retardation, extrapyramidal
symptoms; mild paradoxical excitatory reactions during first 2 wk of treatment
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension,
palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing,
nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting,
difficulty in swallowing, gastric disorders, hepatic dysfunction
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Elevations of blood enzymes: LDH, alkaline phosphatase, AST,
ALT; blood dyscrasias—agranulocytosis, leukopenia
 • Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances,
gynecomastia. Drug dependence with withdrawal syndrome when drug is
discontinued; more common with abrupt discontinuation of higher dosage used
for > 4 mo

Interactions
Drug-drug
• Increased CNS depression with alcohol and other sedating medications, such as
barbiturates and opioids
• Decreased effectiveness with theophyllines
Drug-herb
• Kava kava increases the sedative effects of benzodiazepines; coma has been
reported with concurrent use

Nursing considerations
CLINICAL ALERT!
Name confusion has occurred between lorazepam and alprazolam; use
caution.

Assessment
• History: Hypersensitivity to benzodiazepines, propylene glycol, polyethylene
glycol or benzyl alcohol; psychoses; acute narrow-angle glaucoma; shock; coma;
acute alcoholic intoxication with depression of vital signs; pregnancy; lactation;
impaired liver or kidney function, debilitation
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic
exam; P, BP; R, adventitious sounds; liver evaluation, abdominal exam, bowel
sounds, normal output; CBC, liver and renal function tests

Interventions
• SL administration has more rapid absorption than PO, and bioavailability
compares to IM use.
• Do not administer intra-arterially; arteriospasm, gangrene may result.
• Give IM injections of undiluted drug deep into muscle mass, monitor injection
sites.
• Do not use solutions that are discolored or contain a precipitate. Protect drug from
light, and refrigerate oral solution.
• Keep equipment to maintain a patent airway readily available when drug is given
IV.
• Reduce dose of opioid analgesics by at least half in patients who have received
parenteral lorazepam.
• Keep patients who have received parenteral doses under close observation,
preferably in bed, up to 3 hr. Do not permit ambulatory patients to drive following
an injection.
• Taper dosage gradually after long-term therapy, especially in epileptic patients.
Teaching points
• Take drug exactly as prescribed; do not stop taking drug (long-term therapy)
without consulting health care provider.
• These side effects may occur: Drowsiness, dizziness (may be transient; avoid
driving or engaging in dangerous activities); GI upset (take drug with food);
nocturnal sleep disturbances for several nights after discontinuing the drug if used
as a sedative and hypnotic; depression, dreams, emotional upset, crying.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions,
palpitations, edema of the extremities; visual changes; difficulty voiding.

Adverse effects in Italic are most common; those in Bold are life-threatening.