Topical Ativan (Lorazepam) Gel Should Not Be Used
Topical lorazepam gel is not absorbed through the skin and therefore cannot be effective for treating anxiety or agitation. A definitive pharmacokinetic study demonstrated that none of the lorazepam in ABH (Ativan-Benadryl-Haldol) gel was absorbed in detectable quantities when applied to the skin of volunteers 1.
Evidence Against Topical Lorazepam
No measurable absorption occurs: In a controlled study of 10 healthy volunteers applying standard 1.0 mL doses of ABH gel (containing 2mg lorazepam) to the wrists, plasma concentrations remained below the detection limit of 0.05 ng/mL at all time points up to 240 minutes 1.
Haloperidol also not absorbed: The same study found no detectable haloperidol absorption from the topical gel formulation 1.
Only minimal diphenhydramine absorption: While diphenhydramine showed erratic, limited absorption in some subjects (highest concentration 0.30 ng/mL), these levels were subtherapeutic 1.
Efficacy requires confirmation: The researchers concluded that the efficacy of ABH gel should be confirmed in randomized trials before its use is recommended, given the complete absence of drug absorption 1.
Alternative Routes for Lorazepam Administration
For Patients Able to Swallow
Oral/sublingual lorazepam 0.5-1 mg four times daily as needed is the NICE guideline-recommended approach for anxiety or agitation, with maximum 4 mg in 24 hours 2, 3.
Reduce to 0.25-0.5 mg in elderly or debilitated patients, with maximum 2 mg in 24 hours 2.
Oral tablets can be used sublingually as an off-label route when swallowing is difficult 2.
For Patients Unable to Swallow
Subcutaneous or intravenous lorazepam 1 mg (up to 2 mg maximum) is appropriate for stat dosing 2.
Lower doses of 0.25-0.5 mg subcutaneously/intravenously every 1 hour as needed should be used in older or frail patients, those with COPD, or when co-administered with antipsychotics 2.
Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed is an alternative benzodiazepine for patients unable to swallow 2.
Subcutaneous injection may cause local irritation with lorazepam 2.
Clinical Pitfalls to Avoid
Do not prescribe topical lorazepam gel expecting systemic effects: Despite widespread use in hospice settings for perceived efficacy and low cost, the complete absence of absorption makes this formulation ineffective 1.
Benzodiazepines themselves can cause paradoxical agitation in approximately 10% of patients, as well as delirium and drowsiness 2.
Address reversible causes first: Before initiating any benzodiazepine, explore patient concerns, ensure effective communication and orientation, and treat reversible causes like hypoxia, urinary retention, or constipation 2, 3.
Risk of tolerance and dependence: Regular benzodiazepine use can lead to tolerance, addiction, depression, and cognitive impairment 2.
Caution with combined therapy: Fatalities have been reported with concurrent use of benzodiazepines and high-dose olanzapine 2.