Maximum Dose of Ativan (Lorazepam)
The maximum daily dose of lorazepam for adults is 10 mg/day according to FDA labeling, though standard clinical practice typically limits dosing to 4 mg/24 hours for anxiety management, with elderly or debilitated patients restricted to 2 mg/24 hours. 1, 2
Standard Adult Dosing
- For anxiety or agitation in adults, the maximum is 4 mg in 24 hours, typically given as 0.5-1 mg orally four times daily as needed 2, 3
- The FDA label indicates the usual therapeutic range is 2-6 mg/day in divided doses, but acknowledges daily dosage may vary from 1-10 mg/day 1
- The largest dose should be taken before bedtime when using divided dosing 1
Reduced Dosing for Vulnerable Populations
- Elderly or debilitated patients have a strict maximum of 2 mg in 24 hours, given as 0.25-0.5 mg doses 2, 3
- The FDA recommends an initial dosage of 1-2 mg/day in divided doses for elderly patients, adjusted as needed and tolerated 1
- Lower doses are necessary due to increased risk of falls, cognitive impairment, and paradoxical agitation 3
Emergency/Acute Care Dosing
- For status epilepticus, the maximum single dose is 4 mg IV (0.05-0.1 mg/kg), which may be repeated every 10-15 minutes if needed 2
- For acute agitation, 1 mg SC/IV is recommended with a maximum of 2 mg 3
- For psychosis with agitation, the maximum single dose is 5 mg IM/IV (0.05-0.15 mg/kg), which may be repeated hourly as necessary 2
- For sedation/anxiolysis, the maximum single dose is 5 mg IV given over 2-3 minutes 2
Critical Safety Considerations
- Underdosing in status epilepticus significantly increases progression to refractory status epilepticus - patients receiving less than 4 mg had 87% progression to RSE versus 62% with the full 4 mg dose 4
- Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 2, 3
- Regular use leads to tolerance, addiction, depression, and cognitive impairment 2, 3
- Respiratory depression risk increases dramatically when combined with other sedatives or opioids - monitor oxygen saturation and have respiratory support available 2, 3
- Marked rebound insomnia and withdrawal anxiety occur after discontinuation, with withdrawal sleep disturbance exceeding the initial therapeutic benefit 5
Dosage Escalation Strategy
- When higher dosage is indicated, increase the evening dose before daytime doses 1
- Dosage should be increased gradually to help avoid adverse effects 1
- Always use a gradual taper when discontinuing to reduce withdrawal reactions - if withdrawal occurs, pause the taper or increase back to the previous dose level 1