Recommended Dosage of Lorazepam for Alcohol Withdrawal
For alcohol withdrawal syndrome, lorazepam should be started at 1-4 mg every 4-8 hours for patients with liver dysfunction, or at 6-12 mg/day total dose for general cases, with tapering following resolution of withdrawal symptoms. 1, 2
Dosing Guidelines
- Lorazepam is the preferred benzodiazepine for patients with severe alcohol withdrawal syndrome (AWS), advanced age, recent head trauma, liver failure, respiratory failure, or other serious medical comorbidities, including obesity 1
- For patients with liver dysfunction, the recommended dosage is 1-4 mg PO/IV/IM every 4-8 hours 2
- For general cases, lorazepam is typically started at 6-12 mg/day total dose 1
- Treatment should be tapered following resolution of withdrawal symptoms and should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 1
Special Population Considerations
- Lorazepam is safer than long-acting benzodiazepines for patients with hepatic insufficiency as it doesn't rely on hepatic oxidation 1
- Unlike chlordiazepoxide and diazepam, lorazepam is shorter-acting with no active metabolites, making it more suitable for patients with liver disease 3
- In comparative studies, lorazepam (8 mg/day) has shown similar efficacy to chlordiazepoxide (80 mg/day) in reducing alcohol withdrawal symptoms 3, 4
Administration Protocol
- The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) score can guide treatment intensity—scores >8 indicate moderate AWS and scores ≥15 indicate severe AWS requiring more aggressive treatment 1
- Inpatient treatment is recommended for cases with serious complications, high levels of recent drinking, history of withdrawal seizures or delirium tremens, co-occurring serious medical or psychiatric illness, or failure of outpatient treatment 1, 2
- Thiamine (100-300 mg/day) should be administered before any glucose-containing IV fluids to all AWS patients to prevent Wernicke encephalopathy 1
Potential Side Effects and Monitoring
- Lorazepam may cause more irritability and dizziness compared to chlordiazepoxide during withdrawal treatment 4
- Regular monitoring of vital signs and evaluation of comorbidities such as dehydration, electrolyte imbalance, renal failure, and gastrointestinal bleeding is essential 2
- Conservative management should include fluids, electrolytes, vitamins, and a comfortable environment 1
Common Pitfalls and Caveats
- The CIWA protocol should not be used alone for diagnosis of AWS as high scores may be seen in other conditions 1
- Psychiatric consultation is recommended for evaluation, acute management of AWS, and long-term abstinence planning 1, 2
- Avoid exceeding the recommended treatment duration of 10-14 days to prevent benzodiazepine dependence 1
- Some patients may require higher doses of lorazepam than previously thought to effectively manage alcohol withdrawal symptoms 4