What is the starting dose of lorazepam (Ativan) for adults?

Lorazepam Starting Dose for Adults

For adults with anxiety, the standard starting dose of lorazepam is 2-3 mg/day given in divided doses (typically twice or three times daily), with the largest dose taken at bedtime. 1

Standard Dosing by Indication

Anxiety Disorders

• Initial dose: 2-3 mg/day in divided doses (twice or three times daily) 1
• The usual therapeutic range is 2-6 mg/day, though daily dosage may vary from 1-10 mg/day depending on response 1
• The largest dose should be taken before bedtime 1

Insomnia Due to Anxiety

• Single daily dose of 2-4 mg at bedtime 1
• This applies to insomnia related to anxiety or transient situational stress 1

Acute Agitation (Emergency/Psychiatric Settings)

• 1 mg PRN (orally if cooperative; parenteral if not) 2
• Can be administered as frequently as every hour if needed, though 4-8 hour intervals are often sufficient 2
• Maximum single dose for acute agitation: up to 2 mg IV/subcutaneous 2

Special Population Adjustments

Elderly or Debilitated Patients

• Reduced starting dose: 1-2 mg/day in divided doses 1
• Lower doses (0.25-0.5 mg) may be appropriate if the patient is frail or has respiratory conditions like COPD due to risk of excessive sedation 2
• Elderly patients are especially sensitive to benzodiazepine effects 3

Parenteral Administration (Anesthesia/Procedural Sedation)

• 0.04-0.06 mg/kg IV or IM for preanesthetic medication 4
• This dosing has been shown most effective for antianxiety and antirecall effects 4

Important Dosing Principles

Titration Strategy

• Increase dosage gradually when higher doses are needed to avoid adverse effects 1
• When increasing, the evening dose should be raised before daytime doses 1
• Dose adjustments should be made based on patient response and tolerability 1

Administration with Oral Concentrate

• Must be mixed with liquid or semi-solid food (water, juice, applesauce, pudding) 1
• Use only the calibrated dropper provided 1
• Consume entire mixture immediately; do not store for future use 1

Critical Safety Considerations

Monitoring Requirements

• Monitor for excessive sedation, especially when combined with other CNS depressants 2
• Watch for paradoxical agitation, which occurs in approximately 10% of patients treated with benzodiazepines 2
• Increased fall risk, particularly in elderly patients 2

Discontinuation

• Use gradual taper to reduce risk of withdrawal reactions 1
• If withdrawal symptoms develop, pause the taper or increase to previous dose level, then decrease more slowly 1
• Abrupt discontinuation can cause marked rebound insomnia and increased anxiety 5

Duration Considerations

• Avoid regular, long-term use due to risks of tolerance, addiction, and cognitive impairment 2
• The drug's duration of action (elimination half-life 8-25 hours) makes it unsuitable for outpatient procedures or hospital stays less than 72 hours 4, 6

Common Pitfalls to Avoid

• Underdosing in status epilepticus: While not the primary indication here, it's worth noting that doses less than 4 mg in SE are associated with progression to refractory status 7
• Inadequate dose titration: Starting too high in elderly/debilitated patients increases adverse effects 1
• Abrupt discontinuation: Always taper to prevent withdrawal phenomena 1, 5
• Ignoring drug interactions: Lorazepam potentiates other CNS depressants including alcohol, opioids, and antipsychotics 2