What alternative medication can be used for catatonia management if intramuscular (IM) Ativan (lorazepam) is not available?

Alternative to IM Lorazepam for Inpatient Catatonia

Use IV midazolam as your alternative benzodiazepine for catatonia when IM lorazepam is unavailable, starting with 2-4 mg IV and titrating up to 32 mg daily in divided doses based on response. 1

Primary Alternative: IV Midazolam

• Midazolam is the best-studied alternative to lorazepam for catatonia when IM lorazepam is unavailable, with a 2025 case series demonstrating safety and effectiveness in 6 hospitalized catatonic patients 1

• Patients tolerated IV midazolam doses ranging from 4-32 mg daily without clinically significant respiratory depression, hypotension, or bradycardia 1

• Midazolam appeared at least partially effective as adjunctive therapy in 5 of 6 cases, though maximal improvement occurred after ECT initiation 1

• Start with 2-4 mg IV midazolam and assess response within 30-60 minutes, as midazolam has more rapid onset than lorazepam but shorter duration requiring more frequent redosing 2

Secondary Alternative: IV Diazepam

• IV diazepam is an acceptable alternative if midazolam is also unavailable, as the lorazepam-diazepam protocol has proven efficacy in catatonia 3, 4

• The lorazepam-diazepam protocol rapidly relieved catatonia in 85.7% of patients with catatonia due to general medical conditions and substance-induced catatonia 3

• Administer IV diazepam 0.1-0.3 mg/kg (maximum 10 mg per dose) over 2 minutes to avoid pain at the IV site 5

• Do NOT use IM diazepam as it has erratic absorption and is not recommended 5

Rectal Diazepam as Last Resort

• If IV access is not available and you cannot establish it, rectal diazepam 0.5 mg/kg up to 20 mg can be administered, though absorption may be erratic 5

• This route is explicitly recommended when IV access is unavailable in seizure management guidelines, and the same principle applies to catatonia given benzodiazepines are first-line for both conditions 5

Critical Monitoring Parameters

• Monitor for respiratory depression, hypotension, and bradycardia with any benzodiazepine route, particularly with IV administration 1

• Be prepared to support ventilation, especially if combining benzodiazepines with antipsychotics 5

• Assess catatonia response within 2 hours of first dose - 61.9% of patients responded within 2 hours and 85.7% within one day using the lorazepam-diazepam protocol 4

When to Escalate to ECT

• If the patient remains catatonic after 5 days of adequate benzodiazepine treatment, proceed to ECT 6

• ECT should be considered earlier if benzodiazepine protocol fails or if catatonia is life-threatening 4

• Four patients who failed lorazepam responded promptly to ECT in a prospective study 6

Common Pitfall to Avoid

• Do not use IM diazepam - this is a critical error as absorption is erratic and tissue necrosis can occur 5

• Avoid oral buspirone as an alternative - it takes 2-4 weeks to become effective and is inappropriate for acute catatonia requiring immediate relief 7