What are the contraindications for lorazepam (Ativan)?

Contraindications for Lorazepam (Ativan)

Lorazepam is absolutely contraindicated in patients with hypersensitivity to benzodiazepines or any components of the formulation, and in patients with acute narrow-angle glaucoma 1.

Primary Contraindications

• Hypersensitivity to benzodiazepines or formulation components 1
• Acute narrow-angle glaucoma 1

Relative Contraindications and Precautions

Respiratory Conditions

• Severe respiratory insufficiency 2
• Chronic obstructive pulmonary disease (COPD) 2
• Sleep apnea

Hepatic and Renal Impairment

• Severe hepatic dysfunction 2
• Renal insufficiency (requires dose adjustment) 2
  • Elimination half-life and clinical effects are increased in renal failure 2

Neurological/Psychiatric Conditions

• Myasthenia gravis (unless in imminently dying patients) 2
• History of substance abuse 2
• Dementia with Lewy bodies 2

Pregnancy and Breastfeeding

• Pregnancy (especially first trimester)
• Breastfeeding women

Age-Related Considerations

• Elderly patients require lower dosing due to:
  • Increased sensitivity to sedative effects 2
  • Decreased clearance with age 2
  • Higher risk of paradoxical aggression 2
  • Increased fall risk 2

Other Precautions

• Concomitant use with other CNS depressants, particularly opioids 2
  • Increases risk of respiratory depression and hypotension
• Parenteral formulations contain propylene glycol which can cause toxicity 2
  • Manifests as metabolic acidosis and acute kidney injury
  • Can occur at total daily IV doses as low as 1 mg/kg
  • Monitor serum osmol gap (>10-12 mOsm/L indicates significant propylene glycol accumulation)

Important Clinical Considerations

Withdrawal Phenomena

• Abrupt discontinuation after prolonged use can cause:
  • Rebound insomnia 3
  • Increased anxiety and tension 3
  • Withdrawal symptoms

Side Effects to Monitor

• Memory impairment and confusion 3
• Drowsiness and sedation 2
• Paradoxical agitation 2
• Respiratory depression (especially with opioids) 2
• Hypotension 2

Special Populations

• Elderly patients are significantly more sensitive to sedative effects 2
• Patients with baseline respiratory insufficiency or cardiovascular instability are at higher risk for cardiopulmonary instability 2

Pharmacokinetic Considerations

• Lorazepam is metabolized by the liver 2
• Clearance is reduced in:
  • Hepatic dysfunction 2
  • Elderly patients 2
  • When used with medications that inhibit cytochrome P450 enzyme systems or glucuronide conjugation 2

While the contraindication regarding angle-closure glaucoma has been questioned in some research 4, the official FDA labeling still lists it as a contraindication 1, and clinicians should adhere to these guidelines unless compelling evidence and clinical judgment suggest otherwise.