From the Guidelines
Intravenous (IV) lorazepam (Ativan) is the preferred benzodiazepine for acute seizure management due to its longer duration of action and less redistribution from the brain to peripheral tissues, providing more sustained seizure protection. The typical adult dose is 2-4 mg IV given at 2 mg/minute, which can be repeated once if seizures continue after 5-10 minutes 1. IV lorazepam is preferred over midazolam (Versed) for initial treatment because it has a longer duration of action in the brain (6-12 hours compared to midazolam's 1-6 hours), as noted in various studies 1. However, midazolam (typically 5-10 mg IV for adults) is a reasonable alternative when IV access is difficult, as it can be given intramuscularly, intranasally, or buccally with good absorption. Both medications work by enhancing the inhibitory effects of GABA in the brain, which helps terminate abnormal electrical activity. If administering either medication, be prepared to monitor for respiratory depression and hypotension, and have airway management equipment readily available.
Some key points to consider when choosing between lorazepam and midazolam include:
- Onset of action: Midazolam has a faster onset of action (1-2 minutes) compared to lorazepam, but lorazepam's longer duration of action makes it a better choice for sustained seizure protection 1.
- Duration of action: Lorazepam's duration of action (6-12 hours) is longer than midazolam's (1-6 hours), making it a better choice for initial treatment 1.
- Redistribution: Lorazepam has less redistribution from the brain to peripheral tissues, maintaining therapeutic levels longer 1.
- Administration: Midazolam can be given intramuscularly, intranasally, or buccally, making it a good alternative when IV access is difficult 1.
It's essential to weigh these factors and consider the individual patient's needs when deciding between lorazepam and midazolam for acute seizure management.
From the Research
Benzodiazepines for Seizure Treatment
- The most effective benzodiazepines for treating seizures are lorazepam and midazolam 2, 3, 4.
- Midazolam can be administered intramuscularly, intranasally, or buccally, making it a convenient option for pre-hospital or home settings 2, 5, 3.
- Lorazepam is typically administered intravenously and is often used as a first-line treatment for convulsive status epilepticus 3, 4.
Comparison of Versed (Midazolam) and Ativan (Lorazepam)
- Both midazolam and lorazepam are effective for treating seizures, but midazolam may be more convenient for pre-hospital or home use due to its non-intravenous administration options 2, 5, 3.
- Lorazepam may be more commonly used in clinical settings due to its established efficacy and safety profile 3, 4.
Treatment of Status Epilepticus
- Status epilepticus requires rapid treatment with benzodiazepines, followed by second-line antiepileptic drugs such as phenytoin, valproate, or levetiracetam 2, 3, 4.
- Refractory status epilepticus may require more aggressive treatment with intravenous anaesthetics, such as midazolam or propofol, and close monitoring in an intensive care unit 6.