What is the initial dosing regimen for a patient starting on Ativan (lorazepam)?

Initial Dosing Regimen for Lorazepam (Ativan)

For adult patients starting on lorazepam, the recommended initial dosage is 0.5-1 mg orally two to three times daily, with a total daily dose of 2-3 mg/day for anxiety, and can be adjusted based on clinical response. 1

Dosing by Indication

Anxiety/Anxiolysis

• Initial dose: 0.5-1 mg orally 2-3 times daily 1
• Total daily range: 1-10 mg/day, with most patients requiring 2-3 mg/day 1
• Maximum dose: 10 mg/day 1
• Elderly or debilitated patients: Start with 1-2 mg/day in divided doses 1

Insomnia due to anxiety

• Initial dose: 2-4 mg as a single dose at bedtime 1
• Elderly patients: Start with lower doses (0.5-1 mg) 1

Acute agitation

• Oral: 0.5-1 mg every 4-6 hours as needed 2
• Maximum: 4 mg in 24 hours (2 mg in elderly/debilitated patients) 2
• Sublingual administration: Oral tablets can be used sublingually for faster onset (off-label use) 2

Status epilepticus

• IV: 0.1 mg/kg (up to maximum 4 mg per dose) 3
  • Underdosing is associated with progression to refractory status epilepticus 3

Administration Guidelines

1. Oral concentrate formulation:

   • Mix with liquid or semi-solid food (water, juice, soda, applesauce, pudding)
   • Use only the calibrated dropper provided
   • Consume the mixture immediately after preparation 1

2. Timing of doses:

   • When higher dosage is needed, increase the evening dose before daytime doses 1
   • For insomnia, administer the single daily dose at bedtime 1

Special Populations

Elderly or Debilitated Patients

• Initial dose: 1-2 mg/day in divided doses 1
• Maximum: 2 mg in 24 hours for acute agitation 2
• Increased risk of oversedation, confusion, and falls

Patients with Hepatic or Renal Impairment

• Lower doses may be required due to decreased metabolism and elimination
• Monitor more closely for signs of toxicity

Important Considerations

Side Effects to Monitor

• Sedation and drowsiness (most common)
• Memory impairment and confusion (reported in clinical studies) 4
• Paradoxical agitation (occurs in about 10% of patients) 2
• Increased daytime anxiety with continued use 4

Risk of Dependence and Withdrawal

• Physical dependence can develop with regular use
• Withdrawal symptoms include rebound insomnia, anxiety, and tension 4, 5
• Rebound insomnia typically peaks on the third night after discontinuation 4, 5
• Withdrawal symptoms can be several times worse than baseline symptoms 4

Discontinuation Protocol

• Use gradual tapering to discontinue lorazepam or reduce dosage 1
• If withdrawal reactions develop, pause taper or return to previous dosage level 1
• Subsequently decrease the dosage more slowly

Clinical Pearls

1. Start low, go slow: Begin with the lowest effective dose, especially in elderly patients
2. Monitor for paradoxical reactions: About 10% of patients may experience increased agitation
3. Avoid prolonged use: Risk of dependence increases with duration of treatment
4. Taper gradually: Never abruptly discontinue after prolonged use
5. Avoid alcohol: Concomitant use with alcohol enhances CNS depression

Lorazepam has been shown to effectively manage anxiety associated with hypertension at doses of approximately 3 mg/day with generally mild and transient side effects 6, but always consider the risk-benefit ratio before initiating treatment, particularly for long-term use.