From the Guidelines
Paradoxical reactions to Lorazepam in adolescents are caused by a risk of paradoxical increase in rage, which is not possible to predict unless it has happened previously.
Causes of Paradoxical Reactions
- The exact cause of paradoxical reactions to Lorazepam is not well understood, but it is thought to be related to the individual's response to the medication, rather than a specific dose or administration route 1.
- Short-acting anxiolytics, such as Lorazepam, have been used for chemical restraint with children and adolescents, but they carry a risk of paradoxical increase in rage, which can be unpredictable 1.
- It is essential to seek information about previous reactions to anxiolytics and antihistamines during the initial psychiatric evaluation of patients for whom the use of these agents is contemplated 1.
Important Considerations
- The use of Lorazepam and other anxiolytics in adolescents should be approached with caution, and alternative treatments should be considered when possible.
- Monitoring for signs of paradoxical reactions, such as increased agitation or aggression, is crucial when using Lorazepam in adolescents.
- The combination of Lorazepam with other medications, such as neuroleptics, may increase the risk of side effects, including paradoxical reactions 1.
From the FDA Drug Label
Paradoxical reactions, including anxiety, excitation, agitation, hostility, aggression, rage, sleep disturbances/insomnia, sexual arousal, and hallucinations may occur. Paradoxical reactions have been occasionally reported during benzodiazepine use Such reactions may be more likely to occur in children and the elderly.
The cause of paradoxical reactions to Lorazepam (Ativan) in adolescents is not explicitly stated in the drug label. However, it is mentioned that paradoxical reactions may be more likely to occur in children [2] [3].
- The drug label does not provide a clear explanation for the cause of these reactions in adolescents.
- It only mentions that paradoxical reactions, including anxiety, excitation, and agitation, may occur.
- The label advises that use of the drug should be discontinued if paradoxical reactions occur 3.
From the Research
Paradoxical Reactions to Lorazepam in Adolescents
- The exact cause of paradoxical reactions to Lorazepam in adolescents is not well understood, but several factors have been identified as potential contributors, including idiosyncratic reactions, pre-existing personality traits, and underlying psychological conditions 4, 5, 6.
- Studies have shown that paradoxical reactions to benzodiazepines, including Lorazepam, can occur in patients with a history of anxiety, borderline personality disorder, or other psychological disturbances 5, 6.
- The use of benzodiazepines, including Lorazepam, in patients with a history of substance abuse or dependence may also increase the risk of paradoxical reactions 5, 7.
- In pediatric patients, including adolescents, the use of benzodiazepines for acute management of agitation and aggression has been associated with a low risk of adverse events, including paradoxical excitation 8.
- The mechanism of paradoxical reactions to benzodiazepines is not fully understood, but it is thought to involve the GABA system and the interaction between benzodiazepines and other neurotransmitters, such as serotonin 5, 7.
Risk Factors
- Pre-existing personality traits, such as borderline personality disorder or high-trait anxiety, may increase the risk of paradoxical reactions to Lorazepam 5, 6.
- A history of substance abuse or dependence may also increase the risk of paradoxical reactions 5, 7.
- Idiosyncratic reactions, which are unpredictable and may occur in any patient, are also a potential risk factor for paradoxical reactions to Lorazepam 4, 6.
Treatment Options
- Treatment options for paradoxical reactions to Lorazepam are limited, but may include discontinuation of the medication, dose reduction, or switching to a different medication 6.
- In pediatric patients, including adolescents, the use of benzodiazepines for acute management of agitation and aggression should be carefully monitored, and alternative treatments should be considered if paradoxical reactions occur 8.