What is the recommended dosing for Ativan (lorazepam) in managing alcohol withdrawal?

Lorazepam Dosing for Alcohol Withdrawal

For alcohol withdrawal syndrome, lorazepam should be administered at 1-4 mg PO/IV/IM every 4-8 hours as needed, with symptom-triggered dosing being the preferred approach for most patients. 1

Dosing Approach

Symptom-Triggered Dosing (Preferred Method)

• Use CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-revised) scale to guide dosing
• Categorize withdrawal severity:
  • Mild: CIWA-Ar <8
  • Moderate: CIWA-Ar 8-14
  • Severe: CIWA-Ar ≥15 1
• Administer lorazepam only when symptoms appear (CIWA-Ar ≥8)
• Benefits of symptom-triggered approach:
  • Significantly reduces total medication required (average 37.5 mg vs 231.4 mg with fixed schedule) 2
  • Shorter duration of treatment (20 hours vs 62.7 hours) 2
  • Equally effective for symptom control 2

Fixed-Schedule Dosing

• Consider for patients with:
  • History of severe withdrawal
  • Seizures
  • Delirium tremens
  • Inability to reliably report symptoms
• Initial dose: 2-4 mg every 6 hours
• Additional doses as needed based on symptoms 1

Special Considerations

Liver Dysfunction

• Lorazepam is preferred over long-acting benzodiazepines like diazepam or chlordiazepoxide in patients with:
  • Liver dysfunction
  • Advanced age
  • Respiratory compromise 1
• Advantages of lorazepam:
  • Shorter half-life
  • No active metabolites
  • Less accumulation in hepatic impairment 3, 4

Dosing Adjustments

• Start at lower doses (1-2 mg) for:
  • Elderly patients
  • Patients with hepatic impairment
  • Low body weight
• Higher initial doses (3-4 mg) may be needed for:
  • Severe withdrawal
  • History of seizures
  • High tolerance to alcohol

Monitoring and Tapering

• Assess withdrawal symptoms using CIWA-Ar scale every 1-2 hours initially
• Once stabilized (CIWA-Ar <8), assess every 4-8 hours
• Taper dose over 3-5 days to prevent rebound symptoms
• Monitor for side effects:
  • Sedation
  • Respiratory depression
  • Dizziness (more common with lorazepam than chlordiazepoxide) 4
  • Motor incoordination (occurs in approximately 20% of patients) 5

Adjunctive Treatments

• Thiamine supplementation (100-300 mg/day IV or PO) to prevent Wernicke encephalopathy 1
• Electrolyte replacement (particularly magnesium, potassium, phosphate)
• Adequate hydration 1

Potential Pitfalls

• Avoid abrupt discontinuation which may precipitate withdrawal symptoms
• Be aware that approximately 20% of patients may experience dizziness, motor incoordination, or ataxia without recognizing their impairment 5
• Monitor for paradoxical agitation (occurs in approximately 10% of patients) 1
• Avoid using lorazepam as the sole treatment for preventing relapse; consider acamprosate, naltrexone, or baclofen for relapse prevention after detoxification 1

Lorazepam has been shown to be as effective as chlordiazepoxide in managing alcohol withdrawal symptoms, with the advantage of being safer in patients with liver dysfunction 3, 4. The symptom-triggered approach is strongly recommended as it leads to lower total medication use and shorter treatment duration while maintaining efficacy 2.