Is it acceptable to prescribe oral Ativan (lorazepam) to an adult patient with anxiety prior to a morning Magnetic Resonance Imaging (MRI) procedure, considering their medical history and potential risks?

Yes, Oral Lorazepam is Appropriate for Pre-MRI Anxiety

Prescribe lorazepam 0.5-1 mg orally 60-90 minutes before the morning MRI procedure for this patient's procedural anxiety. 1, 2

Recommended Dosing Protocol

Standard adult dosing:

• Lorazepam 0.5-1 mg orally, administered 60-90 minutes before the MRI 1, 2
• Maximum dose: 4 mg in 24 hours 1
• The medication is FDA-approved for short-term relief of anxiety symptoms 2

For elderly or debilitated patients:

• Reduce dose to 0.25-0.5 mg 1, 2
• Maximum dose: 2 mg in 24 hours 1

Why Lorazepam is Preferred Over Alprazolam

Lorazepam is superior to alprazolam for single-dose procedural anxiety because it offers multiple routes of administration (oral, sublingual, IV) with reliable absorption, whereas alprazolam is associated with difficult withdrawal and lacks flexible administration routes. 1 The National Institute of Mental Health consensus recommends avoiding alprazolam for new patients requiring procedural anxiolysis. 1

Administration Instructions

Mix the concentrated oral solution properly:

• Use only the calibrated dropper provided 2
• Mix with liquid (water, juice, soda) or semi-solid food (applesauce, pudding) 2
• Stir gently and consume the entire mixture immediately—do not store 2

Critical Safety Considerations

Screen for contraindications before prescribing:

• Severe respiratory insufficiency or sleep apnea are absolute contraindications 3
• Known allergy to benzodiazepines 2
• History of substance abuse requires careful consideration (though not an absolute contraindication) 2

Warn the patient about:

• Do not drive or operate machinery after taking lorazepam 2
• Avoid alcohol and other CNS depressants, which can cause severe drowsiness, respiratory depression, coma, or death 2
• Sedation and dizziness are the most common side effects 2

Supporting Evidence

MRI-related anxiety is common and clinically significant:

• 37% of patients undergoing MRI report moderate to severe anxiety 4
• Anxiety during MRI is multifaceted, involving claustrophobia, fear of the unknown, and apprehension about test results 4

Lorazepam's efficacy for procedural anxiety is well-established:

• The National Comprehensive Cancer Network recommends benzodiazepines (lorazepam or alprazolam) for anticipatory anxiety related to medical procedures 3
• Historical clinical trials demonstrate lorazepam provides excellent pre-operative sedation with minimal side effects and no unhappy recollections of the procedure 5
• Lorazepam modulates brain activity in anxiety-related regions including the centromedial amygdala, superior frontal gyrus, and anterior insula 6, 7

Common Pitfalls to Avoid

Timing error:

• Many facilities administer anxiolytics 15-30 minutes before MRI, which is too early for peak effect of oral medications 8
• Ensure administration 60-90 minutes before the procedure for optimal anxiolysis 1, 2

Inadequate monitoring:

• Facilities with standard sedation protocols are more likely to provide appropriate monitoring and post-procedure care 8
• Ensure appropriate monitoring during and after benzodiazepine administration 3

Abrupt discontinuation:

• If the patient requires ongoing benzodiazepine therapy beyond this single dose, use gradual tapering to avoid withdrawal reactions 2
• Sudden cessation can cause seizures, severe mental status changes, and suicidal ideation 2

Alternative Approaches if Lorazepam is Unavailable

Other benzodiazepine options:

• Alprazolam 0.25-0.5 mg orally (though less preferred) 3
• Diazepam 5-10 mg orally 3
• Subcutaneous midazolam 2.5-5 mg if oral route is not feasible 1

Non-pharmacological approaches:

• Consider behavioral therapy or guided imagery if benzodiazepines are contraindicated 3