What is the recommended dose and frequency of Ativan (lorazepam) administration?

Lorazepam (Ativan) Dosing Guidelines

For adult patients requiring lorazepam, the recommended dose is 0.05-0.1 mg/kg IV/IM (maximum 4 mg per dose) for most indications, which can be repeated every 10-15 minutes for continued seizures or every 6-8 hours for anxiety/sedation as needed. 1, 2, 3

Route-Specific Dosing for Adults

Intravenous (IV) Administration

• Status epilepticus: 4 mg given slowly (2 mg/min); may repeat once after 10-15 minutes if seizures continue 2, 4
• Sedation/anxiolysis: 0.05-0.1 mg/kg (maximum 4 mg per dose) given over 2-3 minutes 1
• Important: IV lorazepam must be diluted with an equal amount of compatible diluent before administration 2

Intramuscular (IM) Administration

• Anxiety/agitation: 0.05-0.1 mg/kg up to 4 mg per dose 3
• Acute psychosis with agitation: 1-2 mg IM; may repeat hourly as necessary 1

Oral/Sublingual Administration

• Anxiety disorders: 2-6 mg total daily dose, divided into 2-3 doses 5
• Sublingual rescue therapy for seizures: 0.5-2 mg (median 1 mg) for prolonged or repetitive seizures 6

Frequency of Administration

For Acute Indications

• Status epilepticus: Initial dose, may repeat once after 10-15 minutes if seizures continue 2, 4
• Severe agitation/delirium: May repeat hourly as necessary based on clinical response 1

For Scheduled Use

• Anxiety disorders: Every 8-12 hours for scheduled dosing 1
• Sedation: Every 6 hours when converting from continuous infusions 7

Special Considerations

Age-Related Dosing

• Elderly patients: Use lower doses (typically 50% of standard adult dose) due to risk of prolonged sedation 2
• Half-life considerations: Lorazepam has a half-life of approximately 14 hours in adults, which is significantly longer than other benzodiazepines like midazolam 7

Monitoring Requirements

• Monitor respiratory status and oxygen saturation closely
• Be prepared to provide respiratory support, as respiratory depression is the most significant risk 2, 3
• Monitor for excessive sedation, especially when multiple doses have been administered 2

Important Warnings and Precautions

• Respiratory depression: Equipment to maintain airway patency and support ventilation should be immediately available 2
• Withdrawal risk: When used more frequently than recommended, abrupt discontinuation may precipitate withdrawal reactions including seizures 2, 3
• Avoid in: Severe pulmonary insufficiency, severe liver disease, myasthenia gravis unless in imminently dying patients 1
• Drug interactions: Increased risk of respiratory depression when combined with opioids or other sedatives 2

Common Pitfalls to Avoid

1. Underdosing in status epilepticus: Using less than the recommended 4 mg dose in adults significantly increases the risk of progression to refractory status epilepticus 4

2. Rapid IV administration: Administering IV lorazepam too quickly increases risk of respiratory depression and hypotension; always administer slowly (2 mg/min) 2

3. Inadequate monitoring: Failure to monitor respiratory status after administration can lead to undetected respiratory depression 2, 3

4. Prolonged use: Lorazepam is intended for intermittent, short-term use; prolonged use increases risk of dependence and withdrawal 2, 3

5. Inadequate reversal planning: When administering lorazepam, ensure flumazenil is available for emergency reversal of respiratory depression, though be aware it may precipitate seizures 7

By following these guidelines, clinicians can optimize the safety and efficacy of lorazepam administration while minimizing adverse effects and complications.