What is the recommended dosing and titration schedule for lorazepam (Ativan)?

Lorazepam Dosing and Titration

For anxiety disorders, start with 2-3 mg/day divided into 2-3 doses, with the largest dose at bedtime, and titrate gradually upward as needed to a usual maximum of 6 mg/day (range 1-10 mg/day), increasing the evening dose first when higher dosing is required. 1

Standard Dosing by Indication

Anxiety Disorders

• Initial dose: 2-3 mg/day divided twice or three times daily 1
• Usual range: 2-6 mg/day in divided doses 1
• Maximum range: 1-10 mg/day depending on patient response 1
• Dosing strategy: Largest dose should be taken before bedtime 1
• Titration approach: When higher dosage is indicated, increase the evening dose before daytime doses 1

Insomnia Due to Anxiety

• Single daily dose: 2-4 mg, usually given at bedtime 1

Elderly or Debilitated Patients

• Initial dose: 1-2 mg/day in divided doses 1
• Titration: Adjust gradually as needed and tolerated 1

Emergency/Acute Settings

Status Epilepticus (IV Administration)

• Pediatric dose: 0.1 mg/kg IV every 10-15 minutes (maximum 4 mg per dose) 2
• Alternative pediatric range: 0.05-0.10 mg/kg (maximum 4 mg per dose), may repeat every 10-15 minutes 2
• Adult dose: 0.1-0.3 mg/kg every 5-10 minutes (maximum 10 mg per dose) 3
• Critical consideration: Patients >40 kg should receive the full 4 mg dose rather than weight-based dosing less than 4 mg, as underdosing significantly increases progression to refractory status epilepticus (87% vs 62%, p=0.03) 4

Intramuscular Route (When IV Unavailable)

• Pediatric IM dose: 0.2 mg/kg (maximum 6 mg per dose), may repeat every 10-15 minutes 2

Severe Delirium (Palliative Care)

• Initial dose: 0.5-2 mg every 4-6 hours as adjunct to neuroleptics 3
• Indication: Only for agitation refractory to high doses of neuroleptics 3
• Titration: Adjust starting dose to optimal effect 3

Titration Principles

Upward Titration

• General approach: Increase dosage gradually to avoid adverse effects 1
• Priority: Increase evening dose before daytime doses when higher dosing is needed 1

Downward Titration/Discontinuation

• Method: Use gradual taper to reduce withdrawal risk 1
• If withdrawal occurs: Pause taper or increase to previous dosage level, then decrease more slowly 1

Special Populations

Pediatric Benzodiazepine Weaning (Converting from IV Midazolam)

• Calculation: Take 24-hour midazolam dose and divide by 12 (accounting for lorazepam's potency and half-life) 5
• Initial dosing: Divide calculated lorazepam dose by 4 and give every 6 hours 5
• Weaning rate: Reduce by 10-20% per day 5
• Duration: Four times daily dosing is temporary (initial 48 hours), then transition to less frequent intervals 5

Administration Considerations

Oral Concentrate Preparation

• Mixing: Must be mixed with liquid (water, juice, soda) or semi-solid food (applesauce, pudding) 1
• Technique: Use only the calibrated dropper provided, stir gently, consume entire mixture immediately 1
• Storage: Do not store mixed preparation for future use 1

Critical Safety Monitoring

Respiratory Depression Risk

• Monitoring: Oxygen saturation must be monitored continuously 2
• Preparation: Respiratory support must be immediately available 2
• Increased risk: When combined with other sedative agents 3, 2
• Reversal agent: Flumazenil may reverse life-threatening respiratory depression but will counteract anticonvulsant effects and may precipitate seizures 3, 2

Post-Seizure Management

• Route restriction: Never give oral lorazepam immediately post-seizure due to aspiration risk from decreased responsiveness 2
• Monitoring duration: Continue monitoring for seizure recurrence for at least 2 hours after initial administration 2
• Avoid flumazenil: Do not use to reverse sedation in seizure patients as it will precipitate seizure recurrence 2

Common Pitfalls

• Underdosing in status epilepticus: Doses less than 4 mg in patients >40 kg significantly increase progression to refractory status epilepticus 4
• Abrupt discontinuation: Causes marked rebound insomnia (peak on third night post-withdrawal) and increased anxiety/tension 6
• Inappropriate oral administration: Never give by mouth to patients with decreased responsiveness or in immediate post-seizure period 2
• Prolonged four-times-daily dosing: This schedule is only for initial benzodiazepine conversion (48 hours), not long-term maintenance 5