What is the recommended dosage and treatment duration of Ativan (lorazepam) for a patient with anxiety and panic disorder?

Lorazepam Dosing for Anxiety and Panic Disorder

For anxiety disorders, initiate lorazepam at 2-3 mg/day divided into 2-3 doses (typically 0.5-1 mg per dose), with the largest dose at bedtime; for panic disorder specifically, mean effective doses are approximately 7 mg/day divided throughout the day. 1, 2

Standard Dosing Algorithm

Initial Dosing for Anxiety

• Start with 2-3 mg/day in divided doses (e.g., 1 mg twice daily or 0.5-1 mg three times daily), with the largest dose before bedtime 1
• The usual therapeutic range is 2-6 mg/day, though some patients may require 1-10 mg/day 1
• For acute anxiety episodes, use 0.5-1 mg orally every 4-6 hours as needed, with a maximum of 4 mg/24 hours 3

Panic Disorder-Specific Dosing

• Lorazepam demonstrates comparable efficacy to alprazolam for panic disorder at a mean daily dose of 7 mg/day 2
• This is substantially higher than typical anxiety dosing and reflects the more severe nature of panic disorder 2
• Both lorazepam and other benzodiazepines show rapid onset of antipanic effects that are maintained over 7-8 months without dose escalation 4

Dose Titration Strategy

• Increase dosage gradually to minimize adverse effects 1
• When higher doses are needed, increase the evening dose first before adjusting daytime doses 1
• This approach capitalizes on the sedative effects during sleep while maintaining daytime function 1

Special Population Adjustments

Elderly or Debilitated Patients

• Reduce initial dose to 1-2 mg/day in divided doses (e.g., 0.25-0.5 mg per dose) 1
• Maximum dose should not exceed 2 mg/24 hours in elderly patients 5, 3
• Elderly patients face significantly higher risks of falls, cognitive decline, and paradoxical agitation (occurring in approximately 10% of patients) 3, 6

Hepatic Impairment

• For advanced liver disease, reduce initial dose to 0.25 mg orally 2-3 times daily 3

Treatment Duration and Discontinuation

Duration Considerations

• Benzodiazepines should be reserved for short-term use or when psychological treatments are refused/unavailable 3
• Regular use leads to tolerance, addiction risk, depression, and cognitive impairment 3
• Efficacy is maintained for 7-8 months without dose escalation in panic disorder, though long-term use carries dependency risks 4

Discontinuation Protocol

• Use gradual taper to reduce withdrawal risk 1
• If withdrawal reactions develop, pause the taper or increase back to the previous dose level, then decrease more slowly 1
• Discontinuation difficulties occur in a considerable number of panic disorder patients but can be minimized with proper tapering 4

Administration Details

Oral Concentrate Formulation

• Mix with liquid (water, juice, soda) or semi-solid food (applesauce, pudding) using the calibrated dropper 1
• Consume the entire mixture immediately; do not store for future use 1
• Tablets can be used sublingually when swallowing is difficult 5, 3

Critical Safety Considerations

Contraindications

• Severe pulmonary insufficiency, severe liver disease, and myasthenia gravis (except in moribund patients) 3
• Do not combine with other sedatives due to significantly increased respiratory depression risk 3
• Extreme caution required with concomitant high-dose olanzapine due to reported fatalities 3

Common Pitfalls to Avoid

• Underdosing in panic disorder: The mean effective dose (7 mg/day) is substantially higher than typical anxiety dosing (2-3 mg/day) 2
• Using as monotherapy for delirium-related agitation, which may worsen confusion 6
• Abrupt discontinuation rather than gradual taper 1
• Failing to reduce doses in elderly patients, leading to preventable adverse events 5, 3

Comparative Efficacy Evidence

Lorazepam demonstrates equivalent antipanic efficacy to alprazolam, with both drugs showing significant improvement throughout 6-week trials 2. The primary difference is dosing: lorazepam requires approximately 7 mg/day versus 3 mg/day for alprazolam to achieve comparable effects 2. Both medications are well-tolerated aside from sedative effects, and clonazepam may offer advantages as a first-line agent due to its longer duration of action 4.