Maximum Daily Dose of Ativan (Lorazepam)
The maximum daily dose of lorazepam is 4 mg per 24 hours for standard adult patients, with a reduced maximum of 2 mg per 24 hours for elderly or debilitated patients. 1, 2, 3
Standard Adult Dosing
- The FDA-approved maximum is 10 mg/day, though the usual therapeutic range is 2-6 mg/day divided into multiple doses 3
- For anxiety management, the typical maximum is 4 mg per 24 hours, administered as 0.5-1 mg orally four times daily 1, 2
- The largest dose should be taken before bedtime when using divided dosing 3
Reduced Dosing for Vulnerable Populations
Elderly or debilitated patients require dose reduction to a maximum of 2 mg per 24 hours, given as 0.25-0.5 mg per dose 1, 2
- This reduction is critical due to increased sensitivity and fall risk in older adults 2
- Initial dosing for elderly patients should start at 1-2 mg/day in divided doses 3
Context-Specific Maximum Doses
Acute Agitation or Emergency Use
- For acute agitation, 1-2 mg IV/SC is recommended with a maximum single dose of 2 mg 2
- In status epilepticus, doses of 0.05-0.10 mg/kg (maximum 4 mg per dose) may be repeated every 10-15 minutes as needed 1
Insomnia
- A single daily dose of 2-4 mg at bedtime is appropriate for insomnia due to anxiety or transient stress 3
Critical Safety Considerations
- Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 1, 2
- Regular use leads to tolerance, addiction, depression, and cognitive impairment, necessitating the lowest effective dose for the shortest duration 1, 2
- Respiratory depression risk increases significantly when combined with other sedatives (including opioids), requiring availability of respiratory support 1, 2
- Gradual tapering is mandatory when discontinuing to reduce withdrawal reaction risk 3
Common Dosing Errors to Avoid
- Underdosing in acute situations (such as status epilepticus) increases progression to refractory states - patients receiving less than recommended doses showed 87% progression to refractory status epilepticus versus 62% with appropriate dosing 4
- Avoid using benztropine or trihexyphenidyl if extrapyramidal symptoms develop; instead, decrease the lorazepam dose or switch agents 1
- Do not store diluted oral concentrate for future use - the entire mixture must be consumed immediately 3