What are the contraindications for Ativan (lorazepam)?

Ativan (Lorazepam) Contraindications

Lorazepam is absolutely contraindicated in patients with hypersensitivity to benzodiazepines or any formulation components, and in those with acute narrow-angle glaucoma. 1

Absolute Contraindications

• Known hypersensitivity to benzodiazepines or any components of the lorazepam formulation 1
• Acute narrow-angle glaucoma 1

Critical Clinical Situations Requiring Extreme Caution (Relative Contraindications)

Respiratory Compromise

• Baseline respiratory insufficiency significantly increases risk of benzodiazepine-induced respiratory depression, particularly when lorazepam is combined with opioids or other CNS depressants 2
• Respiratory depression is dose-dependent and more pronounced with concurrent sedative or opioid administration 2

Cardiovascular Instability

• Patients with cardiovascular instability are at high risk for benzodiazepine-induced systemic hypotension, especially when lorazepam is administered with other cardiopulmonary depressants 2
• Hemodynamically unstable patients should avoid loading doses entirely 2

Hepatic Dysfunction

• All benzodiazepines are metabolized by the liver, and lorazepam clearance is significantly reduced in patients with hepatic dysfunction 2
• Delayed emergence from sedation occurs with hepatic impairment due to prolonged elimination half-life 2
• While lorazepam undergoes glucuronidation (less affected than oxidation), infrequent, low doses are least problematic when benzodiazepines must be used in liver disease 3

Renal Failure

• The elimination half-life and duration of clinical effect are increased in patients with renal failure 2
• Prolonged effects occur with renal dysfunction, requiring dose adjustments 4

Elderly Patients

• Elderly patients are significantly more sensitive to sedative effects of benzodiazepines 2, 4
• Benzodiazepine clearance decreases with age 2
• Benzodiazepines should be avoided in older patients with cognitive impairment due to documented decreased cognitive performance 2

Special Toxicity Risk with IV Formulation

• Parenteral lorazepam contains propylene glycol, which can cause metabolic acidosis and acute kidney injury in ICU patients 2
• Total daily IV doses as low as 1 mg/kg can cause propylene glycol toxicity (not just high-dose continuous infusions) 2
• Monitor serum osmol gap: values >10-12 mOsm/L indicate significant propylene glycol accumulation 2

Common Clinical Pitfalls

• Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 4
• Tolerance develops with long-term administration, requiring higher doses to achieve the same effect 2, 4
• Cognitive impairment is associated with long-term use 4
• Withdrawal phenomena include marked rebound insomnia (peak on third night post-discontinuation) and significant increases in tension and anxiety 5
• Memory impairment and confusion can occur even at therapeutic doses 5

Drug Interaction Cautions

• Avoid concurrent use with other medications that inhibit cytochrome P450 enzyme systems or glucuronide conjugation, as this reduces benzodiazepine clearance 2
• Extreme caution with opioid co-administration due to synergistic respiratory depression and hypotension 2