What is the recommended dose of lorazepam (Ativan) for alcohol withdrawal?

Recommended Lorazepam Dosing for Alcohol Withdrawal

For alcohol withdrawal syndrome, lorazepam should be administered at a dosage of 1-4 mg PO/IV/IM every 4-8 hours, with a total daily dosage of 6-12 mg/day, and tapered following resolution of withdrawal symptoms. 1

Dosing Considerations

• Lorazepam is the preferred benzodiazepine for patients with severe alcohol withdrawal syndrome (AWS), advanced age, recent head trauma, liver failure, respiratory failure, other serious medical comorbidities, or obesity 1
• Initial dosing should be 1-4 mg every 4-8 hours as needed, with total daily dosage typically starting at 6-12 mg/day 1
• Dose should be tapered following resolution of withdrawal symptoms 1
• For symptom-triggered regimens, lorazepam can be administered based on Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores rather than fixed schedule to prevent drug accumulation 1

Patient-Specific Considerations

• Lorazepam has advantages over long-acting benzodiazepines (chlordiazepoxide, diazepam) in specific patient populations:

  • Intermediate-acting with no active metabolites, making it safer in patients with liver dysfunction 2
  • Preferred in elderly patients due to reduced risk of oversedation 1
  • Safer in patients with respiratory compromise 1

• Lower starting doses (0.5-1 mg) should be considered in:

  • Elderly or frail patients 1
  • Patients with COPD 1
  • When co-administered with antipsychotics 1

Administration Routes

• Lorazepam can be administered via multiple routes:
  • Oral (PO)
  • Intravenous (IV)
  • Intramuscular (IM) 1
• IV administration may be preferred for rapid control of severe symptoms 1

Efficacy and Outcomes

• Lorazepam is equally effective as other benzodiazepines in reducing alcohol withdrawal symptoms 2, 3
• Hospital admission rates are similar between lorazepam and diazepam-treated patients (17.5% vs 18.7%) 3
• Return visit rates within one week are approximately 24% for discharged patients treated with lorazepam 3

Monitoring and Precautions

• Regular monitoring of vital signs is necessary during treatment 1
• Lorazepam may cause sedation, dizziness, and risk of falls 1
• Subcutaneous injection may cause local irritation 1
• Approximately 20% of patients may experience dizziness, motor incoordination, or ataxia and may not recognize their impairment 4
• Avoid combining with olanzepine due to risk of oversedation and respiratory depression 1

Treatment Duration

• Treatment should be continued until withdrawal symptoms resolve, followed by tapering 1
• When weaning from continuous IV benzodiazepines, lorazepam can be tapered by 10-20% per day 1
• The dosage interval can be gradually increased to every 8 hours, then every 12 hours, then every 24 hours, and then every other day before discontinuation 1