What is the proper usage and dosage of Lorazepam (benzodiazepine) for anxiety and insomnia?

Lorazepam for Anxiety and Insomnia

For anxiety, start lorazepam at 2-3 mg/day divided into 2-3 doses; for insomnia, use a single dose of 2-4 mg at bedtime, with elderly patients starting at 1-2 mg/day. 1

Dosing for Anxiety

• Standard adult dose: 2-3 mg/day divided twice or three times daily 1
• Usual therapeutic range: 2-6 mg/day in divided doses, with the largest dose taken before bedtime 1
• Maximum daily dosage may extend from 1-10 mg/day depending on response 1
• Elderly or debilitated patients: Start at 1-2 mg/day in divided doses, adjusting as tolerated 1
• When increasing dosage, raise the evening dose first before daytime doses 1

Dosing for Insomnia

• Single daily dose of 2-4 mg at bedtime for insomnia due to anxiety or transient situational stress 1
• Lorazepam 1-1.25 mg is approximately equivalent to pentobarbital 100 mg for sleep quality and duration 2
• The 2 mg dose demonstrates moderate effectiveness in both inducing and maintaining sleep 3

Critical Warnings and Limitations

Benzodiazepines like lorazepam are NOT first-line therapy for chronic insomnia. 4 The 2008 American Academy of Sleep Medicine guidelines note that benzodiazepines not specifically approved for insomnia (including lorazepam and clonazepam) might be considered only if duration of action is appropriate or if comorbid conditions exist that might benefit 4

Major Concerns with Lorazepam Use:

• Regular use leads to tolerance, addiction, depression, and cognitive impairment 4
• Paradoxical agitation occurs in approximately 10% of patients 4
• Rebound insomnia is severe and consistent: Sleep disturbance after withdrawal can be several times worse than the initial improvement, peaking on the third night after discontinuation 3, 5
• Rebound anxiety occurs during withdrawal periods, with subjective anxiety increasing above baseline 5

Specific Side Effects:

• Memory impairment and anterograde amnesia, particularly after the first dose 3, 5
• Episodes of confusion, especially in elderly patients 3
• Severe hangover and impaired daytime functioning during the first 3 days 5
• Increased daytime anxiety and tension with continued use 3
• Muscle relaxant effects after awakening 6
• Risk of falls, particularly in elderly or frail patients 4

Special Populations

Elderly Patients:

• Start at 1-2 mg/day in divided doses 1
• Use lower doses (0.25-0.5 mg) when combined with antipsychotics 4
• Higher risk of falls, cognitive impairment, and paradoxical reactions 4

Patients with COPD or Respiratory Issues:

• Use lower doses (0.25-0.5 mg) 4
• Increased risk of respiratory depression, especially when combined with other sedatives 4

Discontinuation Protocol

Never abruptly stop lorazepam. 1 To reduce withdrawal reactions:

• Use a gradual taper to discontinue or reduce dosage 1
• If withdrawal reactions develop, pause the taper or increase back to the previous dose level 1
• Subsequently decrease more slowly 1
• Withdrawal insomnia can be delayed but prolonged, lasting multiple nights 6

Alternative Contexts for Use

Acute Agitation/Delirium (Cancer Patients):

• 1 mg subcutaneous or IV stat (maximum 2 mg) 4
• Can repeat 0.25-0.5 mg every 1 hour as needed in elderly/frail patients 4
• Available routes: oral, sublingual, subcutaneous, IV 4
• May cause delirium itself, drowsiness, and paradoxical agitation 4

Pediatric Seizures:

• IV: 0.05-0.10 mg/kg over 2-3 minutes (maximum single dose: 5 mg) 4
• Peak effect at 3-5 minutes; redose every 3-5 minutes to avoid oversedation 4
• Paradoxical agitation may occur, especially in younger children 4

Administration Details

When using oral concentrate formulation 1:

• Mix with liquid or semi-solid food (water, juice, applesauce, pudding) 1
• Use only the calibrated dropper provided 1
• Consume entire mixture immediately; do not store 1

Bottom Line

Lorazepam should be reserved for short-term use only due to significant risks of dependence, cognitive impairment, and severe rebound phenomena. 4, 3, 5 Infrequent, low doses of short half-life agents are least problematic 4. For chronic insomnia, non-benzodiazepine hypnotics (eszopiclone, zolpidem, zaleplon) or cognitive-behavioral therapy are preferred over lorazepam 4.