From the Guidelines
For elderly patients with chronic kidney disease (CKD), lorazepam is generally the preferred benzodiazepine due to its favorable pharmacokinetic profile and lower risk of accumulation in patients with impaired kidney function 1. When prescribing lorazepam for elderly CKD patients, it is essential to start with a low dose of 0.25-0.5 mg once or twice daily and titrate cautiously to minimize the risk of adverse effects. Some key points to consider when using benzodiazepines in elderly patients with CKD include:
- Lorazepam is metabolized primarily through glucuronidation in the liver, making it less dependent on renal clearance 1
- Oxazepam is another reasonable alternative with similar metabolic properties, and both medications have shorter half-lives compared to long-acting benzodiazepines like diazepam 1
- Benzodiazepines should be used sparingly in elderly patients with CKD, limiting treatment to the shortest duration possible due to increased sensitivity to central nervous system effects 1
- Non-pharmacological approaches for anxiety or insomnia should be tried first whenever possible, and regular monitoring for adverse effects such as excessive sedation, confusion, respiratory depression, and worsening renal function is essential when benzodiazepines are used in this vulnerable population 1 It is also important to note that benzodiazepines, including lorazepam, are considered high-risk medications in older adults and should be used with caution, as they can contribute to cognitive impairment, falls, and other adverse effects 1.
From the FDA Drug Label
Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg. The usual precautions for treating patients with impaired renal or hepatic function should be observed Clinical circumstances, some of which may be more common in the elderly, such as hepatic or renal impairment, should be considered. Greater sensitivity (e.g., sedation) of some older individuals cannot be ruled out. In general, dose selection for an elderly patient should be cautious, and lower doses may be sufficient in these patients
Lorazepam may be used in elderly patients with CKD, but with caution. The dosage should be adjusted carefully, and the patient should be monitored frequently for sedative effects. The initial dosage should not exceed 2 mg. 2 2
From the Research
Preferred Benzodiazepine for Elderly with Chronic Kidney Disease (CKD)
- There is no direct evidence from the provided studies to recommend a specific benzodiazepine for elderly patients with CKD.
- However, studies on lorazepam kinetics in elderly patients and those with chronic renal failure provide some insights 3, 4.
- Lorazepam is biotransformed by glucuronide conjugation and excreted in the urine, and its elimination is not significantly affected by renal failure 3.
- In elderly patients, lorazepam kinetics show small changes, with slightly smaller volumes of distribution and 22% less total clearance compared to young subjects 4.
- These findings suggest that lorazepam may be a suitable option for elderly patients with CKD, but dose adjustment may be necessary due to decreased clearance 4.
- It is essential to consider the potential risks of adverse drug reactions in elderly patients with CKD, particularly when prescribing multiple medications 5, 6.
- Further research is needed to determine the safest and most effective benzodiazepine for elderly patients with CKD, taking into account their unique pharmacokinetic and pharmacodynamic profiles 5, 6.