What is the maximum daily dose of oral Ativan (lorazepam)?

Maximum Daily Dose of Oral Lorazepam (Ativan)

The maximum daily dose of oral lorazepam (Ativan) is 10 mg per day, though most patients require between 2-6 mg/day for optimal therapeutic effect. 1

Dosing Guidelines

Standard Adult Dosing

• Usual therapeutic range: 2-6 mg/day in divided doses 1
• Maximum daily dose: 10 mg/day 1
• Initial dosing:
  • For anxiety: 2-3 mg/day divided into 2-3 doses
  • For insomnia due to anxiety: 2-4 mg as a single dose at bedtime

Special Populations

• Elderly or debilitated patients:
  • Initial dose: 1-2 mg/day in divided doses
  • Titrate gradually as needed and tolerated 1

Administration Recommendations

Dosing Schedule

• When higher dosages are needed, increase the evening dose before the daytime doses 1
• For divided doses, the largest dose should be taken before bedtime 1

Oral Concentrate Administration

If using the oral concentrate formulation:

1. Use only the calibrated dropper provided with the product
2. Mix with liquid or semi-solid food (water, juice, soda, applesauce, pudding)
3. Stir gently for a few seconds
4. Consume the entire mixture immediately
5. Do not store for future use 1

Clinical Considerations

Dose Adjustments

• Dosage should be increased gradually to help avoid adverse effects 1
• When higher dosage is indicated, increase the evening dose before daytime doses 1

Discontinuation

• To reduce withdrawal risk, use a gradual taper when discontinuing lorazepam
• If withdrawal reactions develop, consider pausing the taper or temporarily increasing to the previous dose
• Subsequently decrease the dosage more slowly 1

Cautions

• Benzodiazepines can lead to tolerance and addiction with regular use 2
• Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 2
• Signs and symptoms of withdrawal from benzodiazepine therapy can be delayed 2
• Infrequent, low doses of agents with a short half-life are least problematic 2

Special Situations

Status Epilepticus

• For status epilepticus in adults, the recommended IV dose is 0.1 mg/kg up to a maximum of 4 mg per dose 3
• Underdosing lorazepam in status epilepticus is associated with progression to refractory status epilepticus 3

Weaning from IV Benzodiazepines

When converting from continuous IV midazolam to oral lorazepam:

1. Calculate the 24-hour midazolam dose
2. Divide by 12 (accounting for potency and half-life differences)
3. Divide the calculated lorazepam dose by 4 and administer every 6 hours
4. Wean by 10-20% per day
5. Gradually increase dosage interval to every 8h, then 12h, then 24h, then every other day before discontinuation 2

Remember that lorazepam's sedative effects can persist for at least 4 hours after administration, and its onset of action can take 30-40 minutes even when given intravenously 4.