Lorazepam Subcutaneous Dosing for Seizure Activity in Elderly Patients
For elderly patients with active seizures, administer lorazepam subcutaneously at a reduced dose of 0.5-1 mg every hour as needed, with a maximum of 2 mg in 24 hours due to increased sensitivity in this population. 1
Dosing Recommendations
Initial Dosing
- Starting dose: 0.5-1 mg subcutaneously for elderly patients 1
- Administer every 1-2 hours as needed until seizure cessation
- Maximum daily dose: 2 mg in 24 hours for elderly or debilitated patients 1
Continuous Infusion (if needed)
- If seizures require frequent dosing (more than twice daily), consider a subcutaneous infusion via syringe driver 1
- Start with 5 mg over 24 hours for elderly patients 2
- Reduce dose to 5 mg over 24 hours if eGFR <30 mL/minute 1, 2
Administration Considerations
- Subcutaneous injection may cause local irritation 1
- Monitor for respiratory depression, especially in patients with pulmonary insufficiency
- Avoid rapid administration which may increase risk of adverse effects
- Consider concomitant use of an antiepileptic if seizures persist despite lorazepam
Monitoring Parameters
- Respiratory rate and oxygen saturation
- Level of consciousness
- Blood pressure (risk of orthostatic hypotension)
- Seizure frequency and duration
- Renal function (adjust dose if eGFR <30 mL/minute)
Important Cautions
- Benzodiazepines themselves can cause increased agitation and delirium in elderly patients 1
- Increased risk of falls in elderly patients 1
- May cause paradoxical agitation, especially in elderly 1
- Use with caution in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 1
Evidence Considerations
Research suggests that underdosing of benzodiazepines in status epilepticus can lead to progression to refractory status epilepticus 3. However, elderly patients are more sensitive to benzodiazepines and require lower doses to avoid adverse effects 1, 2.
While intravenous administration is typically preferred for acute seizure management with reported efficacy of 48-80% 4, 5, subcutaneous administration is a viable alternative when IV access is challenging, particularly in palliative care settings 1, 2.
Alternative Routes to Consider
- Sublingual administration (using oral solution) has shown efficacy for acute seizure treatment with 70% of patients with prolonged seizures reporting cessation within 5 minutes 6
- Intranasal lorazepam has demonstrated non-inferiority to intravenous administration in some studies 7
Remember that elderly patients are particularly vulnerable to adverse effects of benzodiazepines, including sedation, respiratory depression, and paradoxical agitation. Always start with the lowest effective dose and titrate cautiously based on clinical response.