From the Guidelines
Ativan (lorazepam) is generally preferred over Versed (midazolam) as first-line therapy for status epilepticus due to its longer duration of action and established efficacy in clinical trials. Both medications are effective benzodiazepines for treating seizures, but they have different administration routes and durations of action.
Key Differences
- Ativan is typically administered at 0.1 mg/kg IV (maximum 4 mg) and has a longer duration of action (12-24 hours) compared to Versed (1-6 hours) 1.
- Versed can be given at 0.1-0.2 mg/kg IV, IM, or intranasally (maximum 10 mg), making it more versatile in administration routes, particularly when IV access is challenging.
- Versed has a faster onset of action (1-5 minutes IV, 5-15 minutes IM/intranasal) than Ativan (2-5 minutes IV), which can be advantageous in rapidly progressing seizures.
Mechanism of Action and Side Effects
- Both medications work by enhancing the inhibitory effects of GABA in the brain, thereby reducing neuronal excitability.
- Common side effects include respiratory depression, hypotension, and sedation, so airway monitoring and support should be available 1.
Clinical Considerations
- For prehospital or home settings where IV access is limited, Versed's intranasal or IM options may be more practical.
- In hospital settings with established IV access, Ativan is often preferred due to its longer duration of action and established efficacy in clinical trials 1.
From the Research
Comparison of Midazolam and Lorazepam for Seizure Management
- Midazolam and lorazepam are both benzodiazepines used for the treatment of seizures, including status epilepticus 2, 3, 4.
- A study comparing midazolam and diazepam for the treatment of status epilepticus in children and young adults found that midazolam was superior to diazepam in terminating seizures 2.
- Another study found that intramuscular midazolam was effective in stopping seizures in children, with a success rate of 94.2% in the home group and 85.3% in the emergency room group 5.
- A comparison of intramuscular midazolam and intravenous lorazepam for the treatment of status epilepticus found that midazolam was superior to lorazepam, with seizures absent on arrival to the emergency department in 73.4% of the midazolam group compared to 63.4% of the lorazepam group 3.
- A review of anticonvulsant drugs for the treatment of acute tonic-clonic convulsions in children found that intravenous lorazepam and diazepam were associated with similar rates of seizure cessation and respiratory depression, and that buccal midazolam or rectal diazepam were acceptable first-line anticonvulsants in the absence of intravenous access 4.
- The same review found that intranasal lorazepam appeared to be as effective as intravenous lorazepam, and that intranasal midazolam was equivalent to intravenous diazepam 4.
- However, the review also noted that the quality of the evidence for some comparisons was low to very low, and that more research was needed to inform clinical practice 4.
Efficacy and Safety
- Midazolam and lorazepam have been shown to be effective in stopping seizures, with midazolam being superior to diazepam in some studies 2, 3.
- The safety of midazolam and lorazepam has been evaluated, with respiratory depression being the most common and clinically relevant side effect 4.
- A review found that lorazepam was significantly associated with fewer occurrences of respiratory depression than diazepam 4.
Routes of Administration
- Midazolam can be administered via various routes, including intramuscular, intranasal, and buccal 5, 3, 4.
- Lorazepam can be administered via intravenous and intranasal routes 3, 4.
- A study found that intranasal midazolam was effective in stopping seizures, with a success rate of 93.3% in the home group and 88.2% in the emergency room group 5.
- Another study found that buccal midazolam was effective in stopping seizures, with a success rate of 91% in the home group and 78.4% in the emergency room group 5.