Should Ativan (lorazepam) be discontinued before surgery?

Perioperative Management of Ativan (Lorazepam)

Ativan (lorazepam) should be continued before surgery with the morning dose taken on the day of the procedure. This recommendation is based on the most recent guidelines and FDA labeling information, which prioritizes patient safety and optimal perioperative outcomes.

Decision Algorithm for Lorazepam Management

General Recommendation:

• Continue lorazepam through the perioperative period
• Take the regular morning dose on the day of surgery
• Avoid abrupt discontinuation due to withdrawal risk

Rationale:

1. Withdrawal Risk: Abrupt discontinuation of benzodiazepines can lead to potentially life-threatening withdrawal reactions, including seizures 1
2. Perioperative Anxiety Management: Continuing lorazepam helps manage preoperative anxiety, which can benefit surgical outcomes 2
3. Medication Safety: The FDA label specifically warns against abrupt discontinuation and recommends gradual tapering when discontinuation is necessary 1

Special Considerations

Elderly Patients:

• Continue lorazepam but be aware of increased sensitivity
• The American Geriatrics Society Beers Criteria notes increased sensitivity to benzodiazepines in older adults 2
• Consider dose adjustment if necessary, but do not discontinue abruptly

High-Risk Surgeries:

• For procedures with anticipated high pain levels, maintain regular dosing
• Implement multimodal pain management strategies
• Consider adjunctive non-opioid analgesics 2

Outpatient/Day Surgery:

• For day-case surgery, be aware that lorazepam may not improve quality of recovery and could potentially delay decrease in postoperative anxiety 3
• However, safety concerns regarding withdrawal still necessitate continuation

Important Caveats and Pitfalls

1. Respiratory Depression Risk: Lorazepam can cause respiratory depression, especially when combined with opioids. Ensure proper monitoring and consider dose adjustments of concurrent opioids 1

2. Sedation Effects: Patients should be warned about increased sedation when lorazepam is combined with anesthetics and analgesics 1

3. Tapering Consideration: If discontinuation is deemed necessary for clinical reasons, implement a gradual taper rather than abrupt discontinuation 1

4. Drug Interactions: Be aware of potential interactions with other perioperative medications, particularly other CNS depressants 2

5. Postoperative Monitoring: Patients on lorazepam may require closer monitoring for excessive sedation in the immediate postoperative period

Conclusion

The most recent evidence and guidelines support continuing lorazepam through the perioperative period, including the morning of surgery. The risks associated with abrupt discontinuation (withdrawal, seizures, increased anxiety) outweigh potential benefits of holding the medication. This approach prioritizes patient safety while maintaining effective anxiety control during the stressful perioperative period.