Maximum Recommended Daily Dose of Lorazepam (Ativan)
The maximum recommended daily dose of lorazepam is 10 mg per day for adults, with most patients requiring 2-6 mg/day given in divided doses. 1
Dosing Guidelines by Indication
For Anxiety
- Initial dose: 2-3 mg/day given in 2-3 divided doses
- Usual range: 2-6 mg/day
- Maximum: 10 mg/day
For Insomnia due to Anxiety
- Single daily dose of 2-4 mg, usually at bedtime
For Elderly or Debilitated Patients
- Initial dose: 1-2 mg/day in divided doses
- Maximum: Lower than standard adult maximum (typically 2-4 mg/day)
- Dose should be adjusted gradually as needed and tolerated
For Status Epilepticus
- IV/IM: 0.05-0.10 mg/kg (maximum: 4 mg per dose)
- May repeat dose every 10-15 minutes if needed for continued seizures 2
For Anxiety or Agitation in Acute Settings
- 0.5-1 mg orally four times a day as required (maximum 4 mg in 24 hours)
- For elderly or debilitated patients: 0.25-0.5 mg (maximum 2 mg in 24 hours) 2
Important Clinical Considerations
Dosage Adjustments
- When higher dosage is indicated, increase the evening dose before the daytime doses
- Dose should be increased gradually to avoid adverse effects
- For patients with renal impairment, dose reduction may be necessary
Potential Adverse Effects
- Sedation and drowsiness
- Cognitive impairment
- Respiratory depression (especially when combined with other CNS depressants)
- Risk of dependence with long-term use
Cautions and Contraindications
- Regular use can lead to tolerance, addiction, depression, and cognitive impairment
- Paradoxical agitation occurs in about 10% of patients 2
- Increased risk of respiratory depression when combined with other sedative agents
- Flumazenil may be administered to reverse life-threatening respiratory depression but will also counteract anticonvulsant effects 2
Long-term Use Considerations
- Most long-term users maintain their initial daily dose or decrease it over time
- Patients often shift from as-prescribed to as-needed patterns of use 3
- Withdrawal symptoms can occur upon discontinuation, including rebound insomnia and increased anxiety 4
Special Populations
Pediatric Patients
For status epilepticus in children:
- IV/IM: 0.05-0.10 mg/kg (maximum: 4 mg per dose)
- May repeat every 10-15 minutes if needed 2
Conversion from IV Midazolam to Oral Lorazepam
For patients on continuous IV midazolam >7 days:
- Calculate the 24-hour midazolam dose
- Divide by 12 (accounting for potency and half-life differences)
- Divide calculated lorazepam dose by 4 and give orally every 6 hours
- Wean by 10-20% per day 2
Remember that benzodiazepines like lorazepam should be used at the lowest effective dose for the shortest duration possible to minimize risks of dependence and adverse effects.