Is Ativan (lorazepam) or Haldol (haloperidol) more sedating?

From the Guidelines

Ativan (lorazepam) is generally considered more sedating than Haldol (haloperidol) for most patients. Ativan is a benzodiazepine that works by enhancing the effect of the inhibitory neurotransmitter GABA in the brain, which produces calming effects, muscle relaxation, and sedation. It typically begins working within 15-30 minutes when given intravenously and 1-2 hours when taken orally. Haldol, on the other hand, is an antipsychotic medication that primarily blocks dopamine receptors and is used to treat psychosis and agitation. While Haldol can cause sedation as a side effect, this is not its primary mechanism of action, and the sedative effect is generally less pronounced than with Ativan.

When comparing the two medications, studies have shown that lorazepam produces a more rapid decrease in agitation scales compared to haloperidol 1. For example, a randomized trial comparing lorazepam with haloperidol found that lorazepam had a more rapid decrease in agitation scales at 1,2, and 3 hours from baseline 1. Another study found that the combination of lorazepam and haloperidol was superior to lorazepam alone in reducing agitation, but lorazepam alone was still more effective than haloperidol alone in some cases 1.

Some key points to consider when choosing between Ativan and Haldol include:

• The primary goal of treatment: if rapid sedation is the primary goal, Ativan may be preferred
• The presence of psychotic symptoms: if psychotic symptoms are present, Haldol may be more appropriate
• The potential for side effects: Haldol can cause extrapyramidal symptoms (EPS) as a side effect, while Ativan can cause respiratory depression and other benzodiazepine-related side effects
• The individual patient's medical history and current condition: medication choice should be individualized based on the specific clinical situation

In terms of dosing, Ativan is typically started at 0.5-2mg orally or 0.5-1mg IV/IM, while Haldol is typically started at 5mg IM or IV. However, the exact dosing will depend on the individual patient's needs and the specific clinical situation. Overall, Ativan (lorazepam) is generally considered a more sedating medication than Haldol (haloperidol), but the choice between the two medications should be based on a careful consideration of the individual patient's needs and the specific clinical situation 1.

From the FDA Drug Label

Apnea, coma, bradycardia, arrhythmia, heart arrest, and death have been reported with the concomitant use of haloperidol and lorazepam The sedating effects of lorazepam and haloperidol can be additive when used together. However, the FDA label does not provide a direct comparison of the sedating effects of lorazepam and haloperidol when used alone.

• Lorazepam is a benzodiazepine with known sedating effects.
• Haloperidol is an antipsychotic that can also cause sedation. It is not possible to conclude which drug is more sedating based on the provided information. 2

From the Research

Sedating Effects of Ativan and Haldol

• Ativan (lorazepam) is a benzodiazepine with pronounced sedating activity 3
• Haldol (haloperidol) is a typical antipsychotic that may control agitation without inducing sedation, but can be associated with extrapyramidal symptoms 3
• The combination of haloperidol and promethazine may be the best choice for sedation based on empirical evidence, as it combines the sedative properties of the antihistamine with the calming action of haloperidol 3

Comparison of Sedating Effects

• A study comparing the combination of intramuscular droperidol/midazolam to haloperidol/lorazepam found that droperidol/midazolam was superior in achieving adequate sedation at 10 minutes 4
• Another study found that the addition of lorazepam to haloperidol resulted in a significantly greater reduction in agitation at 8 hours compared to haloperidol alone 5
• A study comparing oral treatment with risperidone plus lorazepam to intramuscular treatment with haloperidol plus lorazepam found that both treatments were effective in controlling agitation, but had similar sedating effects 6

Key Findings

• Lorazepam has a more pronounced sedating activity compared to haloperidol 3, 5
• The combination of haloperidol and lorazepam can be effective in controlling agitation, but may have varying sedating effects depending on the individual and the specific context 6, 5
• Further research is needed to assess the generalizability and adverse effects of using lorazepam and haloperidol for sedation 5