Is Ativan (lorazepam) 1mg suitable for anxiety management in a patient with Chronic Kidney Disease (CKD) and Impaired Renal Function, pending initiation of dialysis?

From the Guidelines

Ativan (lorazepam) 1mg is not the most suitable choice for anxiety management in a patient with Chronic Kidney Disease (CKD) and Impaired Renal Function, pending initiation of dialysis.

Reasons for Concern

• The provided evidence does not specifically address the use of lorazepam in patients with CKD and impaired renal function 1, 2.
• However, it is known that lorazepam is metabolized by the liver and its metabolites are excreted by the kidneys. In patients with impaired renal function, the accumulation of these metabolites can occur, potentially leading to increased sedation and other adverse effects.

Alternative Anxiolytics

• Diazepam and midazolam are mentioned as safe options for use in renal failure patients, as they are metabolized in the liver and do not require dose adjustment based on renal function 1.
• The recommended doses for diazepam vary from 0.1 to 0.8 mg per kg of body weight in a single oral dose for conscious sedation, while midazolam dosages range from 0.5 to 1 mg·kg − 1 with a maximum of 15 mg 1.

Considerations for CKD Patients

• Patients with CKD often experience a range of symptoms, including anxiety, depression, and sleep disorders, which can impact their quality of life 2.
• Management of these symptoms should be individualized and may involve non-pharmacologic interventions, such as cognitive behavioral therapy, as well as pharmacologic treatments, such as simple sedatives or antidepressants 2.
• It is essential to consult with a nephrologist to determine the best course of treatment for anxiety in patients with CKD and impaired renal function.

From the FDA Drug Label

The usual precautions for treating patients with impaired renal or hepatic function should be observed Lorazepam is poorly dialyzable. Lorazepam glucuronide, the inactive metabolite, may be highly dialyzable.

Anxiety Management in CKD Patient:

• The FDA drug label advises to observe usual precautions for patients with impaired renal function.
• However, it does not provide specific dosage recommendations for patients with Chronic Kidney Disease (CKD) and Impaired Renal Function.
• Additionally, it is noted that lorazepam is poorly dialyzable, which may be a consideration for patients pending initiation of dialysis.
• Given the lack of specific guidance, a conservative approach would be to exercise caution when using Ativan (lorazepam) 1mg in this patient population, and consider alternative treatments or close monitoring of the patient's response to the medication 3.

From the Research

Anxiety Management in CKD Patients

• Anxiety is a common comorbidity in patients with Chronic Kidney Disease (CKD) and can have a significant impact on their quality of life 4.
• The treatment of anxiety in CKD patients can involve both pharmacologic and nonpharmacologic approaches 4.

Lorazepam Kinetics in Renal Impairment

• Studies have shown that lorazepam kinetics are not significantly altered in patients with renal impairment, and no dosage adjustment is necessary for patients with renal disease 5, 6.
• The major route of lorazepam elimination is hepatic biotransformation to lorazepam glucuronide, an inactive, nontoxic metabolite that is eliminated by the kidney 5.
• Hemodialysis can remove a significant amount of lorazepam glucuronide, but not intact lorazepam 5, 6.

Suitability of Ativan (Lorazepam) 1mg for CKD Patients

• Based on the available evidence, Ativan (lorazepam) 1mg may be suitable for anxiety management in patients with CKD and impaired renal function, pending initiation of dialysis, as its kinetics are not significantly altered in renal impairment 5, 6.
• However, it is essential to consider the individual patient's condition, medical history, and other medications before initiating treatment with lorazepam.

Psychological Support for Anxiety Management

• Psychological support, either in-person or online, can be beneficial in reducing anxiety levels in patients with CKD and treated by dialysis 7.
• A treatment of minimum eight sessions can show a significant improvement in the patient's trait and state anxiety levels, as well as foster the achievement of advanced adjustment levels compared to the new clinical status 7.