What is the recommended starting dose and titration schedule for oral lorazepam (Ativan) in a patient with catatonia?

Starting Oral Lorazepam for Catatonia

Begin with an oral lorazepam challenge dose of 2 mg, assess response within 1-2 hours, and if effective, continue with 2-3 mg/day divided into 2-3 doses for up to 5 days. 1, 2, 3

Initial Challenge Dose

• Administer 2 mg oral lorazepam as the initial challenge dose 1, 3
• Assess catatonic symptoms within 1-2 hours after administration using a structured rating scale 2, 3
• A positive response to this initial challenge predicts successful treatment outcome with lorazepam 2, 4
• If the patient responds to the challenge (reduction in catatonic signs), proceed with full treatment protocol 2, 3

Full Treatment Protocol

• Standard dosing: 2-3 mg/day divided into 2-3 doses (typically twice daily or three times daily) 1, 3
• The largest dose should be taken at bedtime 1
• Continue treatment for up to 5 days to assess full response 2, 3, 4
• 76-85% of patients respond within 1-2 days, though some may require the full 5-day trial 2, 5

Dosage Adjustments

• If inadequate response occurs with initial dosing, the dose may be gradually increased up to 6-8 mg/day in divided doses 1, 4
• When increasing dosage, increase the evening dose first before daytime doses 1
• The maximum FDA-approved daily dose is 10 mg/day, though most catatonia patients respond to lower doses 1

Special Populations

• Elderly or debilitated patients: Start with 1-2 mg/day in divided doses 1
• These patients have increased sensitivity and fall risk, requiring more conservative dosing 6

Critical Monitoring Points

• Withhold all neuroleptic medications before starting lorazepam, as antipsychotics can be lethal in catatonia 3
• Monitor for respiratory depression, especially if combined with other sedatives 7, 6
• Assess for paradoxical agitation, which occurs in approximately 10% of patients 6
• If no response occurs within 5 days, proceed to ECT rather than continuing to escalate lorazepam 2, 3, 4

Response Prediction

• Patients with shorter duration of catatonic symptoms prior to treatment have better lorazepam response 2
• Response on Day 1 predicts final outcome - lack of early response suggests ECT will be needed 4
• Severity of catatonia and demographic variables do not predict response to lorazepam 2, 4

Administration Technique

• Lorazepam oral concentrate should be mixed with liquid or semi-solid food (water, juice, applesauce) 1
• Use only the calibrated dropper provided with the product 1
• The entire mixture must be consumed immediately - do not store for future use 1

When to Escalate to ECT

• If lorazepam fails after 5 days of adequate trial 2, 3, 4
• Immediately if malignant catatonia develops with autonomic instability or hyperthermia, without waiting for lorazepam trial 3
• ECT should not be delayed in life-threatening presentations 3