From the Guidelines
Lorazepam is not approved as a primary anti-manic drug, but it can be used as an adjunctive treatment for acute manic episodes in bipolar disorder to manage agitation and anxiety. The role of lorazepam in treating manic episodes is primarily adjunctive, helping to control symptoms such as agitation, anxiety, and insomnia that often accompany manic states while primary mood stabilizers take effect 1.
Key Points:
- Lorazepam is used for its rapid onset of action, usually within 30-60 minutes, to enhance the inhibitory neurotransmitter GABA in the brain, which helps calm excessive neuronal activity.
- Typical dosing ranges from 0.5-2mg every 4-6 hours as needed, with treatment generally limited to 2-4 weeks due to dependence risks.
- It is preferred in acute settings because of its intermediate half-life, rapid onset, and predictable metabolism even in patients with liver impairment.
- Side effects include sedation, dizziness, and coordination problems, and patients should be monitored for respiratory depression, especially when combined with other central nervous system depressants.
- Lorazepam should be tapered rather than abruptly discontinued to prevent withdrawal symptoms, and long-term use should be avoided due to tolerance and dependence concerns, as suggested by the clinical policy for the management of the adult psychiatric patient in the emergency department 1.
Clinical Considerations:
- The use of lorazepam as part of a combination therapy, such as with an oral antipsychotic (risperidone), is recommended for agitated but cooperative patients 1.
- The choice of lorazepam over other benzodiazepines like midazolam may depend on the specific clinical context and the need for rapid sedation versus a more prolonged effect.
From the Research
Role of Lorazepam in Treating Manic Episodes
- Lorazepam is used as an adjunctive treatment to lithium in the management of manic agitation in bipolar disorder 2, 3.
- Studies have shown that lorazepam can be an effective and safe alternative to haloperidol in controlling manic agitation, with fewer side effects 2.
- Lorazepam has been found to be rapid and effective in controlling manic agitation, with few troublesome side effects, and without obvious prolongation of the acute illness 3.
Approval and Recommendations
- Lorazepam is not explicitly approved as an anti-manic drug, but it is recommended as a first-tier option for oral treatment of acute agitation in psychotic and manic episodes, either alone or in combination with haloperidol 4.
- The use of lorazepam in the treatment of manic-depressive illness is supported by some studies, which suggest that it can be effective in controlling symptoms of mania and causing fewer side effects than lithium 5.
Comparison with Other Treatments
- Lorazepam has been compared to other treatments, such as haloperidol, olanzapine, and loxapine, in the management of acute agitation in psychotic and bipolar disorder 4, 6.
- While some studies suggest that olanzapine may be more effective than lorazepam in controlling agitation, others have found no significant difference between the two treatments 6.
- The choice of treatment for manic episodes should be based on individual patient needs and circumstances, as well as the potential risks and benefits of each treatment option 6.