What is the recommended dosing for Ativan (lorazepam)?

Ativan (Lorazepam) Dosing

For anxiety, start with lorazepam 0.5-1 mg orally 2-4 times daily (maximum 4 mg/24 hours), reducing to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg/24 hours). 1, 2, 3

Standard Oral Dosing by Indication

Anxiety Disorders

• Initial dose: 2-3 mg/day divided into 2-3 doses 3
• Typical range: 2-6 mg/day in divided doses, with the largest dose at bedtime 3
• Maximum: 10 mg/day (though most patients require 2-6 mg/day) 3
• Elderly/debilitated: Start with 1-2 mg/day in divided doses 3

Insomnia Due to Anxiety

• Single daily dose: 2-4 mg at bedtime 3

Acute Agitation (Parenteral)

• IV/SC dose: 1 mg (maximum 2 mg) 1
• Lower doses (0.25-0.5 mg) should be used in elderly, frail patients, those with COPD, or when co-administered with antipsychotics 1

Pediatric Dosing

Sedation/Anxiolysis

• IV: 0.05-0.10 mg/kg over 2-3 minutes (maximum single dose: 5 mg), with peak effect at 3-5 minutes 1
• Oral: 0.25-0.50 mg/kg (maximum: 20 mg); children <6 years may require up to 1 mg/kg 1

Route-Specific Considerations

Sublingual Administration

• Oral tablets can be used sublingually (off-label) at the same doses 1

Subcutaneous/Intravenous

• Anxiety/agitation: 2.5-5 mg SC every 2-4 hours as needed 1
• If needed more than twice daily, consider continuous SC infusion starting with 10 mg over 24 hours 1

Critical Dosing Principles

Lorazepam is twice as potent as midazolam with a sixfold longer half-life, so when converting from continuous IV midazolam, divide the 24-hour midazolam dose by 12 to determine the daily lorazepam dose 2

Dose Escalation Strategy

• Increase doses gradually to avoid adverse effects 3
• When higher dosing is needed, increase the evening dose before daytime doses 3

Duration of Treatment

• Limit to acute episodes only with maximum 4 mg/24 hours (2 mg/24 hours in elderly) 2
• If used beyond 1-2 weeks, implement gradual taper to minimize withdrawal symptoms 2
• If withdrawal reactions develop, pause the taper or increase to the previous dose level, then decrease more slowly 3

High-Risk Populations

Elderly Patients

• Reduced starting dose: 0.25-0.5 mg due to increased sensitivity and fall risk 1, 2, 4
• Maximum: 2 mg/24 hours 1, 2

Renal Impairment

• No specific dose adjustment mentioned in guidelines, but use caution 3

Critical Safety Warnings

Respiratory Depression Risk

• Increased risk when combined with other sedatives (opioids, antipsychotics) 1, 4
• Have respiratory support available 1
• Use lower doses (0.25-0.5 mg) when co-administering with antipsychotics 1

Paradoxical Reactions

• Paradoxical agitation occurs in ~10% of patients, especially in younger children 1, 4
• Monitor closely during initial dosing 4

Dependence and Withdrawal

• Regular use leads to tolerance, addiction, depression, and cognitive impairment 2
• Use lowest effective doses infrequently 2
• Long-term users typically maintain or decrease their initial dose over time (mean maintenance dose ~2.7 mg/day in one study) 5

Administration Instructions for Oral Concentrate

• Mix with liquid or semi-solid food (water, juice, applesauce, pudding) 3
• Use only the calibrated dropper provided 3
• Consume entire mixture immediately; do not store 3