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NCBI Bookshelf. Lorazepam is a benzodiazepine medication commonly used as the sedative and anxiolytic of choice in the inpatient setting owing to its fast 1 to 3 minute onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile. This activity covers lorazepam, including mechanism of action, pharmacology, adverse event profiles, eligible patient populations, monitoring, and highlights the interprofessional team's role in the management of lorazepam therapy.

Objectives: Identify the mechanism of action of lorazepam. Summarize the various indications for initiating therapy with lorazepam. Describe the contraindications and adverse events of lorazepam. Review interprofessional team strategies for improving care coordination and communication to properly use lorazepam to improve patient outcomes in the varied scenarios where lorazepam is effective.

Access free multiple choice questions on this topic. Lorazepam is a benzodiazepine medication developed by DJ Richards. It went on the market in the United States in Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast 1 to 3 minute onset of action when administered intravenously. Lorazepam binds to benzodiazepine receptors on the postsynaptic GABA-A ligand-gated chloride channel neuron at several sites within the central nervous system CNS.

It enhances the inhibitory effects of GABA, which increases the conductance of chloride ions into the cell. This shift in chloride ions in hyperpolarization and stabilization of the cellular plasma membrane. The onset of its action is 1 to 3 minutes if administered IV and 15 to 30 minutes if administered IM. Lorazepam reaches its peak plasma time in 2 hours if administered orally. Like most benzodiazepines, adverse reactions to lorazepam include CNS and respiratory depression, which are dose-dependent. More severe effects occur with high doses. Lorazepam is contraindicated in patients with an anaphylactic reaction to lorazepam, any component of the formulation, other benzodiazepines cross-sensitivity with other benzodiazepines may exist , intra-arterial administration, use in neonates or infants, severe respiratory impairment except during mechanical ventilation and acute narrow-angle glaucoma, severe respiratory insufficiency.

There are documented case reports and case-control studies showing an increased risk for cleft palate and cleft lip with the use of lorazepam and other benzodiazepines in the first trimester. Third-trimester use of lorazepam and benzodiazepine is associated with an increased risk of causing neonatal withdrawal symptoms. If lorazepam needs to be used in pregnancy, it should be used with extreme caution, and the benefit has to outweigh the risk. Lorazepam and other benzodiazepines have an increased risk of abuse, misuse, and dependence; these medications are contraindicated in the patient who is actively using illicit substances and drugs.

Except for use in Alcohol withdrawal disorder symptoms and detoxification, lorazepam and other benzodiazepine are contraindicated in patients with a history of alcohol dependence and abuse and not in remission. Increased risk of fatality with the combined use of alcohol and lorazepam in overdose, including death.

Additional contraindications include Hypersensitivity to polyethylene glycol, propylene glycol, or benzyl alcohol, and sleep apnea. Monitor respiratory and cardiovascular status, blood pressure, heart rate, and symptoms of anxiety. With high-dose or continuous IV use or IV use in patients with renal impairment, monitor clinical s of propylene glycol toxicity, serum creatinine, BUN, serum lactate, and osmolality gap. With critically ill patients, monitor the depth of sedation. Lorazepam is a Schedule IV drug, and patients may develop dependence and tolerance with long-term use.

The recommendation is to use the lowest possible effective dose for the shortest period. When stopping lorazepam, it should be tapered by 0. Lorazepam can cause CNS and respiratory depression in overdose. It can lead to hypotension, ataxia, confusion, coma, and can be fatal. Concurrent use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.

Dosage and duration of lorazepam must be limited to the minimum required. Patients require surveillance for s and symptoms of respiratory depression. Lorazepam, as with other benzodiazepines, is rarely associated with elevations in serum ALT, and clinically apparent liver injury from lorazepam is extremely rare.

The clinical pattern of acute liver injury from benzodiazepines is typically cholestatic. Flumazenil is an antidote for benzodiazepine toxicity. Abrupt awakening can cause dysphoria, agitation, and increased adverse effects. Flumazenil has minimal effects on benzodiazepine-induced respiratory depression, and suitable ventilatory support should be available in treating acute benzodiazepine overdose.

Lorazepam, like other benzodiazepine medications, can be a highly addictive medication. As a result, an interprofessional team approach to prescribing and managing these medications is necessary. This team includes the prescribers MDs, DOs, NPs, PAs , nursing staff, and pharmacists, each of whom must be vigilant for s of misuse or adverse effects.

This approach will prevent misuse, unintended adverse events and optimize therapy. Great care is necessary when prescribing lorazepam at high doses or prolonged durations, particularly in patients with a history of substance use disorder or concurrent opioid prescriptions. Managing such patients requires an interprofessional team of healthcare professionals that include nurses, pharmacists, and several specialist physicians to monitor for s of abuse, diversion, or concomitant use with other prescription or non-prescription sedative medications.

Prescribing physicians and pharmacists must monitor treatment, provide patient education, be vigilant in prescribing benzodiazepine such as lorazepam, and use state and federal controlled substance monitoring and diversion databases to identify high-risk patients with multiple and frequent prescriptions for benzodiazepines, opioids, muscle relaxants, and other sedative-hypnotics.

Safe prescribing is only achievable with interprofessional treatment monitored by both the clinician and pharmacist. Lorazepam chemical structure. Contributed from the Public Domain. This book is distributed under the terms of the Creative Commons Attribution 4.

Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Continuing Education Activity Lorazepam is a benzodiazepine medication commonly used as the sedative and anxiolytic of choice in the inpatient setting owing to its fast 1 to 3 minute onset of action when administered intravenously.

Indications Lorazepam is a benzodiazepine medication developed by DJ Richards. Anxiety disorder: Initial starting dose: 2 mg to 3 mg by mouth, can repeat dose 2 to 3 times per day; maximum dosage is 10 mg per day. Insomnia due to anxiety or stress: In patients less than 65 years of age: 0. Premedication for anesthesia: IM 0. Note: In patients older than 50 years of age, the maximum dosage is 2 mg. Status epilepticus: IV 0. Alcohol withdrawal delirium off-label use: IV 1 to 4 mg every 5 to 15 minutes until the patient is calm; Can repeat every hour as need; IM 1 to 4 mg every 30 to 60 minutes until the patient is calm; Can repeat every hour as needed.

Alcohol withdrawal syndrome off-label use : Symptom-triggered regimen: Oral, IM, IV 2 mg to 4 mg per hour as needed; the severity assessment scale must determine the dose. Fixed-dose regimen: Oral, IM, IV 2 mg every 6 hours for four doses, followed by 1 mg every 6 hours for eight additional doses. Note: Symptom-triggered regimen is preferable to the fixed-dose regimens; lower doses and shorter treatment duration are in order.

For psychogenic catatonia off-label use : IM 1 mg to 2 mg; can repeat the dose in 3 hours then again in another 3 hours if the initial and subsequent doses are ineffective; Oral, IM, IV: Initially 1 mg and may repeat in 5 minutes if necessary. If the initial challenge is unsuccessful, one may increase the dose up to 4 to 8 mg per day and may continue treatment for up to 5 days.

Adverse Effects Like most benzodiazepines, adverse reactions to lorazepam include CNS and respiratory depression, which are dose-dependent. Contraindications Lorazepam is contraindicated in patients with an anaphylactic reaction to lorazepam, any component of the formulation, other benzodiazepines cross-sensitivity with other benzodiazepines may exist , intra-arterial administration, use in neonates or infants, severe respiratory impairment except during mechanical ventilation and acute narrow-angle glaucoma, severe respiratory insufficiency.

Monitoring Monitor respiratory and cardiovascular status, blood pressure, heart rate, and symptoms of anxiety. Toxicity Lorazepam can cause CNS and respiratory depression in overdose. Enhancing Healthcare Team Outcomes Lorazepam, like other benzodiazepine medications, can be a highly addictive medication. Review Questions Access free multiple choice questions on this topic. Comment on this article. Figure Lorazepam chemical structure. References 1. Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication.

Curr Opin Support Palliat Care. Leppik IE. Status epilepticus in the elderly. Trends in utilization of benzodiazepine and Z-drugs in Israel. Pharmacoepidemiol Drug Saf. Ned Tijdschr Geneeskd. Hosp Pharm. Premedication to reduce anxiety in patients undergoing coronary angiography and percutaneous coronary intervention.

Open Heart. Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. J Child Adolesc Psychopharmacol. Forensic Sci Int. Naso AR. Optimizing patient safety by preventing combined use of intramuscular olanzapine and parenteral benzodiazepines. Am J Health Syst Pharm. Monitoring opioid and benzodiazepine use and abuse: Is oral fluid or urine the preferred specimen type?

Clin Chim Acta. The fate and risk assessment of psychiatric pharmaceuticals from psychiatric hospital effluent.

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