What can be given to a patient with agitation who is already on lorazepam (Ativan)?

Managing Agitation in a Patient Already on Lorazepam

For a patient with agitation who is already on lorazepam, haloperidol is the recommended first-line agent, starting with 0.5-1 mg orally or subcutaneously as needed. 1

First-Line Options for Agitation Management

When lorazepam alone is insufficient to control agitation, adding an antipsychotic is the most effective approach:

• Haloperidol: 0.5-1 mg orally at night and every 2 hours as needed (maximum 10 mg daily, or 5 mg daily in elderly patients) 1

  • Can be administered subcutaneously at the same dose if oral route is not possible
  • Consider a higher starting dose (1.5-3 mg) for severe distress or immediate danger to others 1
  • Caution: May cause extrapyramidal symptoms (EPSEs) and QTc prolongation 1

• Midazolam: If patient cannot swallow, consider 2.5-5 mg subcutaneously every 2-4 hours as needed 1

  • For frequent dosing (more than twice daily), consider subcutaneous infusion via syringe driver starting with 10 mg over 24 hours 1
  • Reduce dose to 5 mg over 24 hours if eGFR <30 mL/minute 1

Second-Line Antipsychotic Options

If haloperidol is contraindicated or poorly tolerated, consider these alternatives:

• Olanzapine: 2.5-5 mg orally or subcutaneously as a starting dose 1, 2

  • Available as orally disintegrating tablet for easier administration 1, 2
  • Caution: Avoid combining with benzodiazepines due to risk of oversedation and respiratory depression 1
  • Has shown faster onset of action and fewer adverse effects than haloperidol or lorazepam in some studies 3

• Risperidone: 0.5 mg orally (can be given up to every 12 hours if scheduled dosing required) 1

  • Reduce dose in older patients and those with severe renal or hepatic impairment 1
  • Oral risperidone plus lorazepam has shown comparable efficacy to intramuscular haloperidol plus lorazepam 4, 5

• Quetiapine: 25 mg (immediate release) orally as starting dose 1

  • Less likely to cause extrapyramidal symptoms than typical antipsychotics 1
  • May cause sedation, orthostatic hypotension, and dizziness 1

For Severe Delirium with Agitation

• Levomepromazine (Methotrimeprazine): 12.5-25 mg subcutaneously as starting dose for patients unable to swallow 1
  • Use 6.25-12.5 mg in elderly patients 1
  • Can maintain with subcutaneous infusion of 50-200 mg over 24 hours 1
  • Doses >100 mg over 24 hours should be given under specialist supervision 1

Important Considerations

• Address reversible causes of agitation first, including:

  • Exploring patient concerns and anxieties 1
  • Ensuring effective communication and orientation 1
  • Treating medical causes such as hypoxia, urinary retention, or constipation 1

• Medication selection should consider:

  • Patient's ability to swallow 1
  • Renal and hepatic function 1
  • Age and frailty (use lower doses in elderly or debilitated patients) 1
  • Risk of QTc prolongation with certain antipsychotics 1

• Monitoring requirements:

  • Assess for orthostatic hypotension before administering subsequent doses 2
  • Monitor for extrapyramidal symptoms with typical antipsychotics 1
  • Be alert for paradoxical agitation with benzodiazepines 1

Common Pitfalls to Avoid

• Avoid using benzodiazepines alone for delirium-related agitation (except for alcohol or benzodiazepine withdrawal) as they may worsen delirium 1
• Avoid combining olanzapine with benzodiazepines due to risk of oversedation and respiratory depression 1, 2
• Don't overlook treating the underlying cause of agitation while providing symptomatic relief 1
• Avoid excessive sedation that may mask symptoms or cause respiratory depression 1
• Don't exceed maximum recommended doses: haloperidol (10 mg daily, 5 mg in elderly) 1, lorazepam (4 mg in 24 hours, 2 mg in elderly) 1