Can Haldol (haloperidol) and Ativan (lorazepam) be given together?

Haloperidol and Lorazepam Combination Therapy for Acute Agitation

Yes, haloperidol (Haldol) and lorazepam (Ativan) can be safely and effectively administered together, and this combination is often recommended as first-line treatment for acute psychotic agitation. 1

Rationale for Combination Therapy

The combination of haloperidol and lorazepam provides several clinical advantages:

• Synergistic effect: The combination produces faster and more effective sedation than either medication alone 1, 2
• Lower doses: Using both medications together allows for lower doses of each individual agent, potentially reducing side effects 2
• Complementary mechanisms: Haloperidol (an antipsychotic) addresses psychotic symptoms while lorazepam (a benzodiazepine) provides anxiolysis and sedation 1

Dosing Recommendations

For adults with acute agitation:

• Haloperidol: 5 mg IM/IV
• Lorazepam: 2 mg IM/IV
• May repeat every 30-60 minutes as needed 1

For adolescents (>16 years):

• Haloperidol + lorazepam combination is specifically recommended 1
• Adolescent dosing: Haloperidol 0.5-1 mg + Lorazepam 2 mg 1

Administration Considerations

• Both medications can be administered in the same syringe for IM injection 1
• Onset of action:
  • Lorazepam: 20-30 minutes IM
  • Haloperidol: 15-45 minutes IM 1
• Duration of action:
  • Lorazepam: 6-8 hours
  • Haloperidol: 4-8 hours 1

Monitoring Requirements

When administering this combination, monitor for:

1. Respiratory depression: The combination can cause additive CNS depression 3
2. Cardiovascular effects: Monitor for hypotension, bradycardia, and QT prolongation 4
3. Extrapyramidal symptoms (EPS): Haloperidol can cause acute dystonia, akathisia, and other movement disorders 1
4. Excessive sedation: Particularly in elderly patients or those with comorbidities 4
5. Serious adverse events: Rare but serious events including apnea, coma, arrhythmia, heart arrest, and death have been reported with this combination 3

Special Populations

Elderly Patients

• Use with caution in elderly patients with dementia
• Consider lower doses due to increased risk of falls, cognitive impairment, and mortality 4
• FDA black box warning exists for antipsychotics in dementia patients 4

Pediatric Patients

• Specific dosing recommendations exist for adolescents 1
• Use caution in younger children

Clinical Evidence

The efficacy of this combination is well-established:

• Multiple studies demonstrate that haloperidol plus lorazepam is effective for rapid control of agitation 1, 5, 2
• A 2022 study compared haloperidol/lorazepam to droperidol/midazolam, finding both effective but with different onset times 5
• The combination has been used successfully in thousands of medically ill patients with delirium 2

Alternative Options

If oral administration is possible:

• Risperidone (2 mg) plus lorazepam (2 mg) orally has shown similar efficacy to IM haloperidol plus lorazepam 6, 7
• This oral combination may be better tolerated with fewer side effects 6

Cautions and Contraindications

• Respiratory depression: Monitor closely, especially when combined with other CNS depressants 3
• QT prolongation: Haloperidol can prolong QT interval; use with caution in patients with cardiac disease 1
• Anticholinergic effects: May worsen delirium in patients with anticholinergic toxicity 1

In summary, the haloperidol and lorazepam combination is an established, effective approach for managing acute agitation, with substantial evidence supporting its use when rapid control of agitation is needed.