What is the recommended dosing of Ativan (lorazepam) for status epilepticus?

Lorazepam Dosing for Status Epilepticus

For status epilepticus, the recommended dose of lorazepam is 0.05-0.10 mg/kg IV (maximum: 4 mg per dose), which may be repeated every 10-15 minutes if needed for continued seizures. 1

Adult Dosing

• Initial dose: 4 mg IV given slowly (2 mg/min) for patients 18 years and older 2
• If seizures continue or recur after 10-15 minutes observation period, an additional 4 mg IV dose may be administered 2
• Success rate of approximately 65% for initial control of status epilepticus 3

Pediatric Dosing

• 0.05-0.10 mg/kg IV (maximum: 4 mg per dose) 1
• May repeat dose every 10-15 minutes if needed for continued seizures 1
• Safety in pediatric patients has not been established according to FDA labeling 2

Administration Considerations

• Administer IV slowly over 2-3 minutes to avoid respiratory depression 1
• Equipment to maintain a patent airway MUST be immediately available prior to administration 2
• Continuous monitoring of vital signs, especially respiratory status, is essential 2

Efficacy and Comparative Data

• Lorazepam is more effective than phenytoin as initial treatment for overt generalized convulsive status epilepticus (64.9% vs 43.6% success rate) 4
• Equally effective as phenobarbital (58.2%) and diazepam plus phenytoin (55.8%) but easier to use 4
• More effective for generalized tonic-clonic status epilepticus than for partial status epilepticus with altered responsiveness 5
• Comparable efficacy to levetiracetam (76.3% for LEV vs 75.6% for lorazepam) in one randomized study 6

Potential Adverse Effects

• Respiratory depression (most significant risk) 1, 2
• Increased risk of apnea when combined with other sedative agents 1
• Hypotension, especially with rapid administration 6
• Paradoxical agitation may occur, especially in younger children 1

Treatment Algorithm for Status Epilepticus

1. First-line treatment: Lorazepam 0.05-0.10 mg/kg IV (max 4 mg) over 2-3 minutes 1, 2

   • If IV access unavailable, consider rectal diazepam or nasal/buccal midazolam 7

2. If seizures persist after 10-15 minutes:

   • Repeat lorazepam dose (same as initial) 2
   • OR proceed to second-line agent

3. Second-line options if status epilepticus is refractory to benzodiazepines:

   • Phenytoin/Fosphenytoin: 18-20 mg/kg IV (56% success rate) 3
   • Valproate: 20-30 mg/kg IV (88% success rate) 3
   • Levetiracetam: 30-50 mg/kg IV (44-73% success rate) 3
   • Phenobarbital: 10-20 mg/kg IV (58% success rate) 3

4. For refractory status epilepticus:

   • Consider continuous IV midazolam or propofol 7
   • EEG monitoring is recommended 3

Important Precautions

• Flumazenil may reverse life-threatening respiratory depression but will also counteract anticonvulsant effects and may precipitate recurrence of seizures 1
• Intramuscular route is not preferred for status epilepticus as therapeutic levels may not be reached as quickly as with IV administration 2
• Patients should be observed continuously for recurrence of seizures after initial control 2
• Treatment of status epilepticus requires more than just anticonvulsant administration—it involves observation and management of all parameters critical to maintaining vital functions 2

Remember that status epilepticus is a medical emergency requiring rapid intervention to minimize neural damage. The goal is to terminate seizures within 10 minutes to reduce the risk of permanent neurological impairment 8.