Can low-dose Lorazepam (Ativan) be used to manage agitation in a patient with alcohol intoxication?

From the Guidelines

Low-dose lorazepam can be used to manage agitation in a patient with alcohol intoxication, with a typical starting dose of 0.5-1 mg given intravenously or intramuscularly, as recommended by the most recent guidelines 1. When managing agitation in alcohol-intoxicated patients, it is essential to consider the potential risks and benefits of using benzodiazepines like lorazepam.

• The patient's respiratory status should be assessed before administering lorazepam, as benzodiazepines can cause respiratory depression, particularly when combined with alcohol 1.
• Continuous monitoring after administration is crucial, including oxygen saturation, blood pressure, and respiratory rate.
• Lorazepam works by enhancing the effect of GABA, an inhibitory neurotransmitter, which helps reduce agitation and anxiety.
• It is preferred in patients with liver dysfunction due to its non-hepatic metabolism.
• However, caution is necessary regarding potential paradoxical reactions (increased agitation) and the risk of oversedation.
• Always use the lowest effective dose and consider alternative causes of agitation, such as hypoglycemia, hypoxia, head injury, or other medical conditions that may require different interventions.
• According to the most recent guidelines, benzodiazepines are the treatment of choice as monotherapy for alcohol or benzodiazepine withdrawal 1.
• Other studies also support the use of low-dose lorazepam for managing agitation in various clinical settings, including pediatric patients receiving chimeric antigen receptor T cell therapy 1 and patients with COVID-19 symptoms 1.
• The recommended dose of lorazepam may vary depending on the specific clinical context, but a typical starting dose is 0.5-1 mg given intravenously or intramuscularly, which can be repeated every 1-2 hours as needed while monitoring vital signs and level of consciousness 1.

From the FDA Drug Label

Alcoholic beverages should not be consumed for at least 24 to 48 hours after receiving lorazepam injectable due to the additive effects on central-nervous-system depression seen with benzodiazepines in general. Lorazepam injection, like other injectable benzodiazepines, produces additive depression of the central nervous system when administered with other CNS depressants such as ethyl alcohol, phenothiazines, barbiturates, MAO inhibitors, and other antidepressants

The use of low-dose Lorazepam (Ativan) to manage agitation in a patient with alcohol intoxication is not recommended due to the potential for additive central-nervous-system depression.

• The FDA drug label warns against consuming alcoholic beverages for at least 24 to 48 hours after receiving lorazepam injectable.
• The label also states that lorazepam injection produces additive depression of the central nervous system when administered with other CNS depressants, including ethyl alcohol. 2

From the Research

Management of Agitation in Alcohol Intoxication

• Low-dose lorazepam can be used to manage agitation in patients with alcohol intoxication, as benzodiazepines are considered first-line therapy for treating alcohol withdrawal syndrome (AWS) 3.
• Lorazepam is a suitable option for patients with liver disease or the elderly, as its metabolism is minimally affected by age and liver disease 3.
• In cases of acute agitation, lorazepam can be used as a rapid tranquilizer, either alone or in combination with other medications 4.
• The use of low-dose haloperidol is also recommended for treating delirium with acute agitation in hospitalized older people, and lorazepam is often used concurrently 5.
• However, the choice of antipsychotic for acute agitation secondary to alcohol intoxication may impact emergency department length of stay, with droperidol associated with shorter lengths of stay compared to haloperidol and olanzapine 6.

Considerations for Lorazepam Use

• Lorazepam can cause ataxia, sedation, and has additive effects with other CNS depressant drugs 4.
• The pharmacokinetics of lorazepam make it a suitable option for intramuscular administration, with predictable absorption 3.
• Lorazepam is often used in combination with other medications, such as haloperidol, for the treatment of acute agitation 4, 5.