Lorazepam Dosing for Alcohol Withdrawal
For alcohol withdrawal, administer lorazepam at 1-4 mg PO/IV/IM every 4-8 hours, with a total daily dose of 6-12 mg/day, then taper after withdrawal symptoms resolve. 1
Standard Dosing Protocol
The American Association for the Study of Liver Diseases establishes the following dosing framework:
- Initial dose: 1-4 mg every 4-8 hours as needed 1
- Total daily dose: 6-12 mg/day 1
- Routes: Oral (PO), intravenous (IV), or intramuscular (IM) 1
- Duration: Continue until withdrawal symptoms resolve, then taper 1
The FDA-approved dosing range for lorazepam spans 1-10 mg/day for various indications, with most anxiety patients requiring 2-3 mg/day in divided doses 2. However, alcohol withdrawal typically requires the higher end of this range at 6-12 mg/day 1.
Symptom-Triggered vs. Fixed-Schedule Dosing
Symptom-triggered regimens using CIWA-Ar scores are preferred over fixed schedules to prevent drug accumulation 1. This approach administers lorazepam based on objective withdrawal severity rather than predetermined intervals, reducing total benzodiazepine exposure while maintaining symptom control.
Special Population Adjustments
Elderly or Frail Patients
- Start with 0.5-1 mg doses (lower than standard 1-4 mg) 1
- Lorazepam is specifically preferred in elderly patients due to reduced oversedation risk 1
- The American Geriatrics Society endorses lorazepam over long-acting benzodiazepines in this population 1
Patients with Comorbidities
Lorazepam is the preferred benzodiazepine for patients with: 1
- Liver failure (no active metabolites requiring hepatic metabolism)
- Respiratory failure or COPD (use lower starting doses of 0.5-1 mg)
- Advanced age
- Recent head trauma
- Other serious medical comorbidities
Concurrent Antipsychotic Use
When co-administered with antipsychotics, reduce starting dose to 0.5-1 mg 1. Never combine with olanzapine due to severe oversedation and respiratory depression risk 1.
Route Selection
- IV administration is preferred for rapid control of severe withdrawal symptoms 1
- All three routes (PO, IV, IM) are equally acceptable based on clinical scenario 1
- IM absorption is reliable, unlike some other benzodiazepines
Tapering Protocol
After withdrawal symptoms resolve: 1
- Reduce dose by 10-20% per day when weaning from continuous IV benzodiazepines
- Gradually increase dosing intervals: every 8 hours → every 12 hours → every 24 hours → every other day
- Then discontinue
- Use gradual taper to reduce withdrawal reaction risk 2
- If withdrawal reactions develop, pause the taper or increase back to the previous dose level 2
Clinical Evidence Supporting Dosing
Research demonstrates that lorazepam 8 mg/day (tapered over 8 days) is equally effective as chlordiazepoxide 80 mg/day for mild-to-moderate withdrawal 3, 4. One study showed patients required a median of 2.0 mg/day (range 0.1-17 mg/day) for symptom control 5, though this represents symptom-triggered dosing which typically uses less total medication. The 6-12 mg/day guideline recommendation 1 aligns with the 8 mg/day used successfully in controlled trials 3, 4.
Critical Monitoring Requirements
- Monitor vital signs regularly during treatment 1
- Assess for sedation, dizziness, and fall risk 1
- Watch for rebound withdrawal symptoms if tapering too rapidly 2
Common Pitfall to Avoid
Do not use fixed low doses in patients with multiple previous detoxifications. These patients may require higher doses and are at increased risk for treatment failure with inadequate dosing. The standard 6-12 mg/day range remains appropriate, but symptom-triggered dosing should guide total requirements 1. In extreme cases, doses exceeding 1,600 mg/day have been required for severe delirium tremens 6, though this is exceptionally rare.