What is the appropriate use of Ativan (lorazepam) for managing acute anxiety?

From the Guidelines

Ativan (lorazepam) is appropriate for managing acute anxiety at a dose of 0.5-1 mg orally four times a day as required, with a maximum of 4 mg in 24 hours, as recommended by the most recent guidelines 1. When considering the use of Ativan for acute anxiety, it is essential to prioritize the lowest effective dose for the shortest duration possible to minimize the risk of adverse effects and dependence.

• The dose should be adjusted according to the patient's response and tolerance, with a maximum daily dose not exceeding 4 mg.
• In elderly or debilitated patients, the dose should be reduced to 0.25-0.5 mg, with a maximum of 2 mg in 24 hours, due to increased sensitivity to benzodiazepines 1.
• Ativan can be used sublingually (off-label use) if necessary, but this should be done with caution and under medical supervision.
• The use of Ativan should be limited to 2-4 weeks, including a gradual tapering period to prevent withdrawal symptoms, as prolonged use can lead to physical dependence and tolerance.
• Patients with a history of substance abuse, respiratory disorders, or those taking other CNS depressants should be avoided or used with caution, as they may be at increased risk of adverse effects.
• Ativan is contraindicated during pregnancy and should be used cautiously in elderly patients due to increased sensitivity to benzodiazepines.
• Other guidelines also support the use of benzodiazepines, such as lorazepam, for the management of acute anxiety and agitation, but emphasize the importance of using the lowest effective dose and monitoring for adverse effects 1.

From the FDA Drug Label

Lorazepam is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms. The appropriate use of Ativan (lorazepam) for managing acute anxiety is for the short-term relief of symptoms.

• Key points:
  • Indicated for anxiety disorders
  • Indicated for short-term relief of anxiety symptoms
  • Not typically used for everyday life stress
  • Long-term use (more than 4 months) has not been assessed 2

From the Research

Appropriate Use of Ativan (Lorazepam) for Managing Acute Anxiety

• Ativan (lorazepam) is a benzodiazepine that is widely used for the management of acute anxiety and agitation 3.
• The primary use of lorazepam, when administered intravenously (IV), has been in the treatment of acute attacks of anxiety and agitation 4.
• Lorazepam can be considered a clinically effective means of treating the acutely agitated patient, with improvements seen across a variety of outcomes related to agitation 3.
• In patients with hypertension-associated anxiety, lorazepam has been shown to significantly relieve symptoms of anxiety compared to placebo 5.
• Lorazepam has also been used as an adjunctive treatment to lithium for the clinical management of manic agitation, offering an efficacious and safe alternative to haloperidol in a subgroup of bipolar patients 6.

Dosage and Administration

• The dose of lorazepam required for sedation and anxiolysis can vary, but most patients can be controlled with 3 mg/day 5 or intermittent intravenous injection of 1-10 mg 7.
• Lorazepam can be administered orally or intravenously, depending on the clinical situation and the patient's needs.

Safety and Efficacy

• Lorazepam has a well-characterized safety profile, with common adverse events including dizziness, sedation, and somnolence 3, 7.
• The combination of lorazepam and haloperidol has been shown to be superior to either agent alone in the treatment of agitation, but with no differences between monotherapy with the individual agents 3.
• Lorazepam has been compared to other medications, such as midazolam and olanzapine, and has been found to be safe and clinically effective in various clinical settings 3, 7.