From the Guidelines
I would advise stopping lorazepam immediately in this patient since the catatonic symptoms have resolved and the patient is now experiencing delirium with an elevated CRP, suggesting a possible underlying infection or inflammatory process, as benzodiazepines like lorazepam can worsen delirium, particularly in the setting of infection, by enhancing GABA activity and further disrupting neurotransmitter balance 1. The patient's fluctuating sedation likely represents a combination of benzodiazepine effect and delirium.
- Key considerations in managing this patient include:
- Investigating and treating the underlying cause of the rising CRP and delirium, which may include obtaining cultures, chest imaging, and starting empiric antibiotics if infection is suspected.
- Monitoring for re-emergence of catatonic symptoms and considering alternative treatments such as electroconvulsive therapy (ECT) or switching to a different medication like memantine or amantadine that won't exacerbate the delirium.
- Avoiding the use of benzodiazepines as a first-line agent in the management of delirium, as they are sedating, have been identified as deliriogenic, and are associated with a clear risk of falls in patients with some functional mobility 1. Instead, consider using antipsychotics like olanzapine, quetiapine, or aripiprazole, which may offer benefit in the symptomatic management of delirium and appear less likely to be associated with extrapyramidal side effects (EPSEs) than first-generation antipsychotics 1.
- The use of pharmacological interventions in the management of delirium should be limited to patients who have distressing delirium symptoms or if there are safety concerns where the patient is a potential risk to themselves or others, and medications should be used in the lowest effective dose and for a short period of time only 1.
From the Research
Stopping Lorazepam in a Patient with Catatonia
- The patient is currently being managed for catatonia with high-dose lorazepam, but now presents with delirium and an up-trending CRP, as well as fluctuating sedation without overt signs of catatonia.
- According to the study by 2, lorazepam could be tapered slowly and stopped without the reemergence of catatonic signs in a patient who developed catatonia after epileptic seizures.
- The study by 3 found that 76% of patients who received a complete trial of lorazepam had their catatonic signs resolved, and a positive response to an initial parenteral challenge predicted final lorazepam response.
- However, the current patient's presentation of delirium and up-trending CRP may indicate a need to reassess the treatment plan, as there is no direct evidence to suggest when to stop lorazepam in this specific scenario.
- The study by 4 suggests that lorazepam is a reasonable initial choice in the treatment of catatonia, with rapid consideration for ECT if there is no rapid response to lorazepam, but does not provide guidance on when to stop lorazepam.
- The study by 5 found that lorazepam and diazepam can rapidly relieve catatonic signs in patients with schizophrenia, but does not address the issue of stopping lorazepam in a patient with delirium and up-trending CRP.
Considerations for Stopping Lorazepam
- The patient's delirium and up-trending CRP may be indicative of an underlying medical condition that needs to be addressed.
- The fluctuating sedation without overt signs of catatonia may suggest that the patient is no longer responding to lorazepam or that the catatonia has resolved.
- The decision to stop lorazepam should be based on a thorough assessment of the patient's overall clinical condition, including the resolution of catatonic signs and the management of any underlying medical conditions.
- Further research is needed to provide guidance on when to stop lorazepam in patients with catatonia who develop delirium and up-trending CRP.