Lorazepam for Nausea: Adjunctive Use Only
Lorazepam (Ativan) is not recommended as a single-agent antiemetic but serves as a useful adjunct to standard antiemetic therapy, particularly for chemotherapy-induced nausea, anticipatory nausea, and anxiety-related nausea. 1
Primary Role: Adjunctive Therapy
Lorazepam should never be used alone for nausea management but can be combined with primary antiemetics such as 5-HT3 antagonists (ondansetron), NK1 receptor antagonists, or dexamethasone 1
The drug's primary benefit in nausea control comes from its anxiolytic and amnesic properties rather than direct antiemetic effects 1, 2
Standard adjunctive dosing is 0.5-2.0 mg orally, intravenously, or sublingually every 4-6 hours when used alongside chemotherapy regimens 1
Specific Clinical Scenarios Where Lorazepam Adds Value
Anticipatory Nausea and Vomiting
Lorazepam is most effective for anticipatory nausea (conditioned nausea occurring before chemotherapy) when combined with standard antiemetics 1
The mechanism involves blocking memory consolidation of unpleasant chemotherapy experiences—approximately 46% of patients in one study did not recall receiving chemotherapy when given lorazepam 2
Alprazolam 0.25-0.5 mg orally three times daily (starting the night before treatment) is an alternative benzodiazepine for anticipatory nausea, though elderly patients should start at 0.25 mg 2-3 times daily 1
Anxiety-Contributing Nausea
When anxiety clearly contributes to nausea and vomiting, adding a benzodiazepine to dopamine receptor antagonists (haloperidol, metoclopramide, prochlorperazine) is reasonable 1
In palliative care settings with non-specific nausea, consider lorazepam as an adjunct if anxiety is a contributing factor 1
Chemotherapy-Induced Nausea
Lorazepam demonstrated efficacy in reducing psychological distress and delayed chemotherapy-induced nausea when combined with other antiemetics 3
Approximately 70% of patients showed satisfactory responses when lorazepam was given before and after cisplatin infusion, with 80% experiencing no significant post-chemotherapy anxiety 2
Important Dosing Modifications
Hepatic Impairment
In advanced liver disease, lorazepam is preferred over alprazolam due to simpler metabolism with no active metabolites 4, 5
Dosing in liver disease: 1-4 mg orally/IV/IM every 4-8 hours 4
Alprazolam requires dose reduction to 0.25 mg orally 2-3 times daily in advanced liver disease 1, 4
Route of Administration
When oral route is not feasible due to ongoing vomiting, rectal, subcutaneous, or intravenous administration should be used 1, 4
Continuous intravenous or subcutaneous infusions of antiemetics (including lorazepam) may be necessary for intractable nausea 1
Critical Limitations and Adverse Effects
Regular use can lead to tolerance, addiction, depression, and cognitive impairment 1
Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 1
Adverse reactions include perceptual disturbances, urinary incontinence, hypotension, drowsiness (reported in 15% of patients), and rare cases of severe transient amnesia 2, 3
Elderly patients are especially sensitive to benzodiazepine effects—doses should be gradually reduced when discontinuing therapy 1
Recommended Antiemetic Algorithm
For chemotherapy-induced nausea (high emetogenic risk):
- Primary: NK1 antagonist + 5-HT3 antagonist + dexamethasone 1
- Adjunct: Lorazepam 0.5-2.0 mg every 4-6 hours if anxiety present or anticipatory nausea risk 1
For non-chemotherapy nausea:
- Primary: Dopamine antagonists (metoclopramide, haloperidol, prochlorperazine) or 5-HT3 antagonists 1
- Adjunct: Lorazepam only if anxiety is a contributing factor 1
For refractory nausea: