What is the recommended risk profile education for patients prescribed Ativan (lorazepam)?

Risk Profile Education for Patients Prescribed Ativan (Lorazepam)

Patients prescribed Ativan (lorazepam) must be educated about its significant risks including respiratory depression, sedation, physical dependence, withdrawal reactions, and potential for abuse, misuse, and addiction.

Key Risks to Discuss with Patients

Respiratory Depression and Sedation

• Lorazepam can cause respiratory depression, especially when combined with opioids, which may result in profound sedation, respiratory depression, coma, and death 1
• Patients should be advised not to drive or operate heavy machinery until the effects of the medication have been determined, as benzodiazepines impair psychomotor function 1
• Elderly patients are significantly more sensitive to the sedative effects of benzodiazepines and require careful monitoring and dose adjustment 2

Dependence and Withdrawal

• Continued use of lorazepam may lead to clinically significant physical dependence 1
• Abrupt discontinuation or rapid dosage reduction can precipitate acute withdrawal reactions, which can be life-threatening (e.g., seizures) 1
• Some patients may develop a protracted withdrawal syndrome with symptoms lasting weeks to more than 12 months 1
• Withdrawal symptoms include rebound insomnia, increased tension, and anxiety, which may be several times worse than the original symptoms 3

Abuse, Misuse, and Addiction

• Lorazepam exposes users to risks of abuse, misuse, and addiction, which can lead to overdose or death 1
• Abuse and misuse often involve doses greater than the maximum recommended dosage and commonly involve concomitant use of other medications, alcohol, or illicit substances 1
• Patients should be assessed for risk of abuse, misuse, and addiction before and throughout treatment 1

Drug Interactions

• Patients should be educated about dangerous drug interactions, particularly with opioids, alcohol, and other CNS depressants 1
• Concurrent use with valproate or probenecid may increase plasma concentrations of lorazepam, requiring approximately 50% dose reduction 1
• Clozapine combined with lorazepam may produce marked sedation, excessive salivation, hypotension, ataxia, delirium, and respiratory arrest 1

Special Populations

• Patients with depression should be monitored for suicidal ideation, as benzodiazepines should not be used in such patients without adequate antidepressant therapy 1
• Lorazepam should be used with caution in patients with compromised respiratory function (e.g., COPD, sleep apnea syndrome) 1
• Patients with impaired renal or hepatic function require careful monitoring and possible dose adjustments 1

Safe Storage and Overdose Prevention

• Controlled substances should be stored safely away from individuals at risk of misuse and/or overdose 2
• Family members should be educated on the medications, their risks, and signs of overdose 2
• The poison control number should be readily visible 2
• Clinicians should teach patients and their caregivers about opioid overdose and the use of naloxone to reverse overdose; a naloxone rescue kit should be readily available when prescribing benzodiazepines, especially when combined with opioids 2

Appropriate Use Guidelines

• Lorazepam should generally be prescribed for short-term use only (2-4 weeks) to minimize risks of dependence and adverse effects 4
• The lowest effective dosage should be prescribed to minimize risks 1
• For elderly or debilitated patients, dosage should be adjusted carefully according to patient response; the initial dosage should not exceed 2 mg 1
• Gradual tapering is required when discontinuing lorazepam to reduce the risk of withdrawal reactions 1
• For older adults, a recommended approach is withdrawing 25% of the daily benzodiazepine dose each week, though more gradual tapering may be necessary for long-term users 5

Monitoring Requirements

• Patients on long-term therapy should have periodic blood counts and liver-function tests 1
• Patients should be monitored for signs of abuse, misuse, and addiction throughout treatment 1
• Monitoring should be increased in frequency when factors that increase risk for opioid-related harms are present, especially when benzodiazepines are co-prescribed with opioids 2

Alternative Treatment Options

• Non-pharmacological approaches such as cognitive-behavioral therapy, supportive psychotherapy, and problem-solving therapy should be considered as alternatives or adjuncts to medication 5
• Integrative strategies including relaxation techniques, music therapy, and mindfulness may help manage anxiety 5
• For older adults with anxiety, alternative pharmacological options may include buspirone or certain antidepressants, which have less risk of cognitive impairment and falls 5