Lorazepam Dosing for Adults
For anxiety, start with 2-3 mg/day divided into 2-3 doses; for insomnia, use 2-4 mg as a single bedtime dose; in elderly or debilitated patients, begin with 1-2 mg/day in divided doses. 1
Standard Adult Dosing
Anxiety Disorders
- Initial dose: 2-3 mg/day given in divided doses (twice or three times daily) 1
- Usual range: 2-6 mg/day in divided doses, with the largest dose taken before bedtime 1
- Maximum: Up to 10 mg/day may be used, though this represents the upper limit 1
- Dose escalation: When higher dosages are needed, increase the evening dose first before adjusting daytime doses 1
Insomnia
- Recommended dose: 2-4 mg as a single dose at bedtime 1
- This indication is specifically for insomnia due to anxiety or transient situational stress 1
- Note that the 2017 American Academy of Sleep Medicine guidelines for chronic insomnia do not include lorazepam among recommended agents, focusing instead on other benzodiazepines like temazepam (15 mg) and triazolam (0.25 mg) 2
Special Populations
Elderly or Debilitated Patients
- Initial dose: 1-2 mg/day in divided doses 1
- Adjust gradually as needed and tolerated 1
- Critical consideration: Benzodiazepines with short half-lives like lorazepam are least problematic in elderly patients, though they still carry risks of paradoxical agitation, tolerance, addiction, depression, and cognitive impairment in approximately 10% of elderly patients 2
Renal or Hepatic Impairment
- The palliative care guidelines note that doses of medications dependent upon hepatic or renal failure should be decreased 2
- Start at the lower end of the dosing range and titrate cautiously 1
Administration Guidelines
Oral Concentrate Formulation
- Must be mixed with liquid (water, juice, soda) or semi-solid food (applesauce, pudding) 1
- Use only the calibrated dropper provided 1
- Stir gently and consume the entire mixture immediately—do not store for future use 1
Dose Titration
- Increase gradually when needed to avoid adverse effects 1
- Allow adequate time between dose adjustments to assess response 1
Discontinuation Protocol
Use a gradual taper to reduce withdrawal risk 1:
- If withdrawal reactions develop, pause the taper or increase back to the previous dose level 1
- Then decrease more slowly 1
- Abrupt discontinuation can cause marked rebound insomnia (peaking on the third night post-withdrawal) and significant increases in tension and anxiety 3
Critical Clinical Considerations
Duration of Use Limitations
- Research demonstrates that lorazepam causes rebound anxiety near the end of its metabolic activity, making it a poor choice for chronic insomnia treatment 4
- The drug should probably not be used in patients whose expected hospital stay is less than 72 hours due to its prolonged duration of action 5
- Not appropriate for outpatient settings requiring same-day discharge 5
Delirium Management Context
- In palliative care settings with severe delirium, lorazepam 0.5-2 mg every 4-6 hours may be added for refractory agitation despite high doses of neuroleptics 2
- This represents adjunctive use rather than primary treatment 2
Common Pitfalls
- Underdosing: While data exists showing underdosing in status epilepticus settings increases refractory cases 6, this is not directly applicable to anxiety/insomnia dosing
- Daytime impairment: Lorazepam 0.5 mg TID can cause increased morning anxiety and confusion, though it may reduce evening tension 4
- Rare hepatotoxicity: Though uncommon, drug-induced liver injury has been reported with lorazepam use 7