From the Guidelines
Chronic lorazepam use should be limited to short-term treatment (2-4 weeks) whenever possible due to significant risks of dependence, tolerance, and withdrawal. Lorazepam is a benzodiazepine that works by enhancing the effect of GABA, an inhibitory neurotransmitter in the brain, producing sedative, anxiolytic, and anticonvulsant effects. For patients already on long-term therapy, gradual tapering is essential when discontinuing - typically reducing the dose by 10-25% every 1-2 weeks, with slower reductions as the dose decreases, as suggested by the EMPOWER trial 1. Common withdrawal symptoms include rebound anxiety, insomnia, irritability, and in severe cases, seizures.
Alternative Treatments
Alternative treatments for anxiety disorders include:
- SSRIs like sertraline (50-200mg daily) or escitalopram (10-20mg daily), which are more appropriate for long-term management.
- Cognitive behavioral therapy, which is also highly effective and should be considered as a first-line or adjunctive treatment. For elderly patients, lorazepam doses should be reduced (typically starting at 0.5mg) due to increased sensitivity and risk of falls, cognitive impairment, and respiratory depression, as noted in the study by 1. Regular monitoring for side effects and periodic reassessment of the need for continued therapy is crucial for all patients on benzodiazepines.
Key Considerations
Key considerations for managing benzodiazepine use include:
- Gradual tapering when discontinuing long-term therapy
- Regular monitoring for side effects
- Periodic reassessment of the need for continued therapy
- Consideration of alternative treatments, such as SSRIs and cognitive behavioral therapy
- Reduced doses for elderly patients due to increased sensitivity and risk of adverse effects, as recommended by 1 and 1.
From the FDA Drug Label
The continued use of benzodiazepines, including lorazepam may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Lorazepam oral concentrate can cause physical dependence and withdrawal reactions. Do not suddenly stop taking lorazepam oral concentrate Stopping lorazepam oral concentrate suddenly can cause serious and life-threatening side effects, including, unusual movements, responses or expressions, seizures, sudden and severe mental or nervous system changes, depression, seeing or hearing things that others do not see or hear, an extreme increase in activity or talking, losing touch with reality, and suicidal thoughts or actions It is not known if lorazepam oral concentrate is safe and effective for use for longer than 4 months.
The effects of long-term lorazepam (Ativan) use include:
- Physical dependence: The risk of physical dependence increases with longer treatment duration and higher daily dose.
- Withdrawal reactions: Stopping lorazepam suddenly can cause serious and life-threatening side effects.
- Unknown safety and efficacy: It is not known if lorazepam is safe and effective for use for longer than 4 months 2, 2, 2.
From the Research
Effects of Long-Term Lorazepam Use
- Long-term use of lorazepam, a benzodiazepine, can lead to physical dependence and addiction 3, 4, 5, 6, 7
- Studies have shown that prolonged treatment with benzodiazepines, including lorazepam, is common practice despite clinical recommendations of short-term use 4
- The chronic nature of anxiety may require long-term low-dose benzodiazepine treatment, including lorazepam, for some patients 3
- However, long-term use of lorazepam can lead to tolerance and dependence, which can constitute a serious clinical problem 5
Risks Associated with Long-Term Lorazepam Use
- Withdrawal seizures have been reported in patients who abruptly stopped taking lorazepam 5
- Long-term users of lorazepam may experience withdrawal symptoms, including anxiety, insomnia, and seizures, when trying to discontinue the medication 4, 6
- The risk of addiction and negative consequences of use is higher with lorazepam due to its reinforcing capabilities and relatively severe withdrawal syndrome 7
Clinical Characteristics of Long-Term Lorazepam Users
- Long-term users of lorazepam tend to use low therapeutic doses and may shift their use from an as-prescribed to an as-needed pattern 6
- Individuals with a history of anxiety disorders, personality disorders, and past history of alcohol dependence may be more likely to use lorazepam long-term 6
- Persistent use of lorazepam for therapeutic purposes does not necessarily represent abuse or addiction, but rather may be a result of chronic psychiatric conditions 6