What maintenance regimen should be initiated for a patient who responded well to an Ativan (lorazepam) challenge dose?

Lorazepam Maintenance Regimen After Positive Challenge Response

After a successful lorazepam challenge dose, initiate maintenance therapy at 2-3 mg/day divided into 2-3 doses (typically 1 mg twice daily or 0.5-1 mg three times daily), with the largest dose given at bedtime. 1, 2

Standard Maintenance Dosing

The FDA-approved maintenance regimen ranges from 2-6 mg/day in divided doses, with most patients requiring 2-3 mg/day for anxiety management. 2

• The typical starting regimen is 1 mg twice daily or 0.5-1 mg three times daily, adjusting based on response 1, 2
• Maximum daily dose should not exceed 4 mg/24 hours in standard adult patients 1
• When dose escalation is needed, increase the evening dose first before adjusting daytime doses 2

Critical Dosing Modifications

For elderly or debilitated patients, reduce the initial dose to 0.5-1 mg/day in divided doses (0.25-0.5 mg per dose), with a maximum of 2 mg/24 hours. 1, 3, 2

• Elderly patients have increased sensitivity to benzodiazepines and higher fall risk, necessitating conservative dosing 1, 3
• The dose should be increased gradually only when needed and tolerated 2

Duration and Discontinuation Strategy

Limit lorazepam treatment to the acute episode only, avoiding chronic maintenance beyond 1-2 weeks whenever possible. 1

• Regular benzodiazepine use leads to tolerance, addiction, depression, and cognitive impairment 1
• When discontinuation is appropriate, use a gradual taper to reduce withdrawal risk rather than abrupt cessation 1, 2
• If withdrawal reactions develop during tapering, pause the taper or increase back to the previous dose level, then decrease more slowly 2
• Abrupt discontinuation after prolonged use can cause rebound insomnia and marked increases in anxiety above baseline levels 4

Important Clinical Caveats

Monitor for paradoxical agitation, which occurs in approximately 10% of patients treated with benzodiazepines. 1, 3

• Respiratory depression risk increases when combined with other sedatives; ensure respiratory support is available 1
• Use scheduled dosing rather than as-needed dosing for consistent therapeutic effect 5
• The lowest effective doses should be used to minimize adverse effects including sedation, cognitive impairment, and dependence 1