What is the recommended dose of lorazepam (Ativan) for acute agitation?

Recommended Dosage of Lorazepam for Acute Agitation

For acute agitation in adults, lorazepam should be administered at 0.5-1 mg orally four times a day as needed (maximum 4 mg in 24 hours), with dose reduction to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours). 1

Dosing Guidelines by Route of Administration

Oral Administration (Patient Able to Swallow)

• Lorazepam 0.5-1 mg orally four times a day as needed (maximum 4 mg in 24 hours) 1
• Reduce dose to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours) 1
• Oral tablets can be used sublingually as an off-label route of administration 1

Parenteral Administration (Patient Unable to Swallow)

• For patients who cannot take oral medication, midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed is recommended instead of lorazepam 1
• In pediatric patients, lorazepam can be administered at 0.05-0.15 mg/kg IM/IV, which may be repeated hourly as necessary (maximum single dose: 5 mg) 1

Comparative Efficacy

• Benzodiazepines (lorazepam or midazolam) are effective as monotherapy for the initial treatment of acutely agitated undifferentiated patients in the emergency department 1
• When rapid sedation is required, droperidol may be more effective than lorazepam, with studies showing that IV droperidol produces better sedation than IV lorazepam after 5 minutes 1, 2
• The combination of an oral benzodiazepine (lorazepam) and an oral antipsychotic (risperidone) is recommended for agitated but cooperative patients 1, 3
• The combination of parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in acutely agitated psychiatric patients 1

Special Considerations and Monitoring

• Monitor for respiratory depression, especially when lorazepam is combined with other sedative agents 1, 2
• Be prepared to support ventilation if respiratory depression occurs 1
• Flumazenil may be administered to reverse life-threatening respiratory depression caused by lorazepam, but it may also counteract the anticonvulsant effects and potentially precipitate seizures 1
• Lorazepam may increase the risk of falls, particularly in elderly patients 1

Combination Therapy Options

• For delirium with agitation, consider adding lorazepam to haloperidol if the patient remains agitated after antipsychotic administration 1
• The combination of oral risperidone (2 mg) plus lorazepam (2 mg) has been shown to be as effective as intramuscular haloperidol (5 mg) plus lorazepam (2 mg) for rapid control of agitation and psychosis 3
• Oral risperidone plus lorazepam has demonstrated effectiveness and good tolerability as an alternative to conventional antipsychotics for acute psychosis in emergency psychiatry 4

Common Pitfalls to Avoid

• Avoid excessive dosing in elderly or debilitated patients; use reduced doses (0.25-0.5 mg) in these populations 1
• Be cautious when combining lorazepam with other sedative agents due to increased risk of respiratory depression 1, 2
• Consider that lorazepam alone may be less effective than droperidol or combination therapy for rapid sedation in severely agitated patients 2
• Remember that benzodiazepines like lorazepam can themselves cause increased agitation and delirium in some patients 1

By following these evidence-based dosing recommendations and considering the patient's specific circumstances, lorazepam can be effectively and safely used for the management of acute agitation in emergency settings.