What is the preferred dose of a oral (PO) anti-anxiety agent, such as lorazepam (Ativan), in an Emergency Department (ED) situation for acute anxiety?

Preferred Oral Anti-Anxiety Agent in the Emergency Department

For acute anxiety in the Emergency Department setting, lorazepam 0.5-1 mg orally is the preferred medication, administered up to four times daily as needed with a maximum of 4 mg in 24 hours. 1

Dosing Guidelines for Lorazepam in the ED

Standard Adult Dosing

• Initial dose: 0.5-1 mg orally 1
• Frequency: Can be given up to four times daily as needed 1
• Maximum daily dose: 4 mg in 24 hours 1

Special Populations

• Elderly or debilitated patients: 0.25-0.5 mg orally 1
• Maximum daily dose for elderly: 2 mg in 24 hours 1

Administration Considerations

• Oral tablets can be used sublingually (off-label) if rapid absorption is desired 1
• For cooperative patients, oral administration is preferred over parenteral routes 2
• FDA guidance recommends mixing lorazepam oral concentrate with liquid or semi-solid food such as water, juices, or applesauce for administration 3

Alternative Routes When Oral Administration Not Possible

If the patient is unable to swallow or is uncooperative:

• Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 1
• For frequent dosing needs (more than twice daily), consider subcutaneous infusion via syringe driver 1

Clinical Approach to Anxiety Management in the ED

1. First address reversible causes of anxiety:

   • Explore patient concerns and anxieties
   • Ensure effective communication and orientation
   • Treat medical causes (e.g., hypoxia, urinary retention, constipation) 1

2. Pharmacological intervention:

   • For cooperative patients with anxiety: lorazepam 0.5-1 mg PO
   • For patients with psychotic agitation: consider combination therapy with an antipsychotic 2

Combination Therapy Considerations

• The combination of lorazepam with haloperidol has been shown to produce faster sedation than monotherapy in psychiatric patients with agitation 2
• For cooperative agitated patients, the combination of oral lorazepam with oral risperidone may be effective 2

Monitoring and Safety

• Monitor for respiratory depression, especially when combining with other CNS depressants
• Reduce dose to 5 mg over 24 hours if estimated glomerular filtration rate (eGFR) is <30 mL/minute 1
• Avoid in patients with significant risk of torsades de pointes 2

Common Pitfalls to Avoid

• Overdosing in elderly patients: Always use reduced doses (0.25-0.5 mg) in elderly or debilitated patients 1
• Prolonged use: Plan for tapering to avoid withdrawal reactions 3
• Inadequate monitoring: Regularly assess therapeutic response and adverse effects 2
• Failure to consider underlying cause: Different etiologies of agitation may respond better to different medications (e.g., benzodiazepines preferred for agitation due to intoxication) 2

Lorazepam has demonstrated efficacy in treating acute anxiety with rapid onset of action, making it particularly suitable for emergency department use. Studies have shown significant reduction in anxiety symptoms within 30-60 minutes of administration 4, 5.