Lorazepam Nasal Spray for Seizures: Not FDA-Approved, Use Diazepam Nasal Spray Instead
There is no FDA-approved lorazepam nasal spray for seizure management. Diazepam nasal spray (Valtoco) is the only FDA-approved intranasal benzodiazepine for acute seizure treatment in patients ≥6 years with epilepsy, specifically for seizure clusters. 1, 2
Why Diazepam Nasal Spray, Not Lorazepam
While lorazepam remains the gold standard for intravenous first-line treatment of status epilepticus (65% efficacy, superior to diazepam's 56%), it does not have an FDA-approved nasal formulation. 3 The intranasal route requires specific pharmaceutical formulation to ensure reliable absorption and bioavailability—diazepam nasal spray has been specifically engineered and validated for this purpose. 2
Clinical Role of Diazepam Nasal Spray
Diazepam nasal spray is indicated for outpatient/home rescue treatment of seizure clusters (acute repetitive seizures), not for in-hospital status epilepticus management. 1, 2
Specific Indications
- Acute Cluster Treatment (ACT): Prevents progression of seizure clusters—87.4% of clusters terminated with a single dose over 24 hours. 4
- Rapid and Early Seizure Termination (REST): Stops ongoing seizures expected to be prolonged—67.3% of seizure clusters were treated within 5 minutes of onset. 4
- Early treatment is critical: Seizure clusters treated in <5 minutes had median total duration of 4 minutes versus 23 minutes when treated ≥5 minutes after onset. 5
Practical Advantages Over Alternatives
- Superior to rectal diazepam: Less pharmacokinetic variability, more reliable bioavailability, and socially acceptable administration. 2
- Safe with concomitant benzodiazepines: 75.3% of patients in long-term studies used chronic benzodiazepines with no cardiorespiratory depression reported. 1
- High effectiveness: Only 10-11% required a second dose within the seizure cluster, regardless of chronic benzodiazepine use. 1
When to Use IV Lorazepam Instead
For in-hospital status epilepticus or actively seizing patients in the emergency department, use IV lorazepam 4 mg at 2 mg/min, not nasal formulations. 6, 3
- IV lorazepam has 65% efficacy for terminating status epilepticus, the highest quality evidence (Class I) for first-line therapy. 3
- If seizures persist after 2 doses (8 mg total), immediately escalate to second-line agents: valproate 30 mg/kg IV (88% efficacy, 0% hypotension), levetiracetam 30 mg/kg IV (68-73% efficacy), or fosphenytoin 20 mg PE/kg IV (84% efficacy, 12% hypotension risk). 6, 7
Alternative Home Rescue Option: Sublingual Lorazepam
If diazepam nasal spray is cost-prohibitive (intranasal benzodiazepines are expensive 8), sublingual lorazepam oral concentrate solution (0.5-2 mg) is an off-label but effective alternative for home rescue treatment:
- 66% of patients with repetitive seizures had no further seizure activity after treatment. 8
- 70% with prolonged seizures had cessation within 5 minutes. 8
- No serious adverse events reported with home doses; 31% developed moderate/severe sedation. 8
- Critical limitation: Requires refrigeration, which 44% of patients reported limited treatment access. 8
Critical Safety Considerations
- Have airway equipment immediately available before administering any benzodiazepine—respiratory depression can occur, especially when combined with other sedatives. 3
- Simultaneously search for reversible causes: hypoglycemia (treat with 50 ml of 50% dextrose IV), hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, or withdrawal syndromes. 6, 3
- Do not use if seizure has already self-terminated—a single self-limiting seizure does not require acute benzodiazepine treatment. 3
Common Pitfall to Avoid
Do not confuse outpatient seizure cluster management with in-hospital status epilepticus treatment. Diazepam nasal spray is designed for caregiver administration at home to prevent emergency department visits, not as a substitute for IV benzodiazepines in acute hospital settings where IV access is available. 2, 4