LORazepam (lor-az-e-pam)

Ativan

Classification

Therapeutic: anesthetic adjuncts, antianxiety agents, sedative/hypnotics Pharmacologic:

benzodiazepines

Schedule IV Pregnancy Category D

Indications

Anxiety disorder (oral). Preoperative sedation (injection). Decreases preoperative

anxiety and provides amnesia. Unlabeled Use: IV: Antiemetic prior to chemotherapy. Insomnia, panic
disorder, as an adjunct with acute mania or acute psychosis.

Action

Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter.

Therapeutic Effects:Sedation. Decreased anxiety. Decreased seizures.

Pharmacokinetics

Absorption: Well absorbed following oral administration. Rapidly and completely

absorbed following IM administration. Sublingual absorption is more rapid than oral

and is similar to IM.

Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast
milk.

Metabolism and Excretion: Highly metabolized by the liver.

Half-life: Full-term neonates: 18– 73 hr; Older children: 6– 17 hr; Adults: 10– 16

hr.

TIME/ACTION PROFILE (sedation)

ROUTE ONSET PEAK DURATION

PO 15–60 min 1–6 hr 8–12 hr

IM 30–60 min 1–2 hr† 8–12 hr

IV 15–30 min 15–20 min 8–12 hr

Contraindications/Precautions
Contraindicated in: Hypersensitivity; Cross-sensitivity with other benzodiazepines may exist; Comatose
patients or those with pre-existing CNS depression; Uncontrolled severe pain; Angle-closure glaucoma;
Severe hypotension; Sleep apnea; OB, Lactation: Use in pregnancy and lactation may cause CNS
depression, flaccidity, feeding difficulties, hypothermia, seizures, and respiratory problems in the
neonate; discontinue drug or bottle-feed.

Use Cautiously in: Severe hepatic/renal/pulmonary impairment; Myasthenia gravis; Depression;

Psychosis; History of suicide attempt or drug abuse/substance use disorder; COPD; Sleep apnea; Pedi:
Use cautiously in children under 12 yr. Inq doses, benzyl alcohol in injection may cause potentially fatal
“gasping syndrome” in neonates; Geri:Lower doses recommended for geriatric or debilitated patients;
Hypnotic use should be short-term.

Adverse Reactions/Side Effects CNS: dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred
speech, forgetfulness, confusion, mental depression, rhythmic myoclonic jerking in pre-term infants,
paradoxical excitation. EENT: blurred vision. Resp: respiratory depression. CV:rapid IV use only—APNEA,
CARDIAC ARREST, bradycardia, hypotension.GI: constipation, diarrhea, nausea, vomiting, weight gain
(unusual). Derm: rashes. Misc: physical dependence, psychological dependence, tolerance.

Interactions

Drug-Drug: Additive CNS depression with other CNS depressants including alcohol, antihistamines,
antidepressants, opioid analgesics, clozapine, and othersedative/hypnoticsincluding other
benzodiazepines. Maypthe efficacy oflevodopa. Smokingmayqmetabolism andpeffectiveness. Valproate
and canqlevels (pdose by 50%).Oral contraceptivesmayplevels.

Drug-Natural Products: Concomitant use of kava-kava,valerian, orchamomile canqCNS depression.

Route/Dosage

PO (Adults): Anxiety—1– 3 mg 2– 3 times daily (up to 10 mg/day). Insomnia— 2– 4 mg at bedtime.

PO (Geriatric Patients or Debilitated Patients): Anxiety—0.5– 2 mg/day in divided doses initially.Insomnia

—0.25– 1 mg initially,qas needed.

PO (Children): Anxiety/sedation—0.02– 0.1 mg/kg/dose (not to exceed 2 mg) q 4– 8 hr. Preoperative

sedation—0.02– 0.09 mg/kg/dose.

PO (Infants): Anxiety/sedation—0.02– 0.1 mg/kg/dose (not to exceed 2 mg) q

4– 8 hr. Preoperative sedation—0.02– 0.09 mg/kg/dose.

SL (Adults and adolescents 18 yr): Anxiety—2– 3 mg/day in divided doses,

not to exceed 6 mg/day; preoperative sedation—0.05 mg/kg, up to 4 mg total given

1– 2 hr before surgery.

SL (Geriatric Patients and debilitated patients): 0.5 mg/day, dose may be adjusted as necessary.

IM (Adults): Preoperative sedation—50 mcg (0.05 mg)/kg 2 hr before surgery

(not to exceed 4 mg).

IM (Children): Preoperative sedation—0.02– 0.09 mg/kg/dose.

IM (Infants): Preoperative sedation—0.02– 0.09 mg/kg/dose.

IV (Adults): Preoperative sedation—44 mcg (0.044 mg)/kg (not to exceed 2 mg)

15– 20 min before surgery. Operative amnestic effect—up to 50 mcg/kg (not to

exceed 4 mg). Antiemetic—2 mg 30 min prior to chemotherapy; may be repeated q

4 hr as needed (unlabeled). Anticonvulsant—50 mcg (0.05 mg)/kg, up to 4 mg;

may be repeated after 10– 15 min (not to exceed 8 mg/12 hr; unlabeled).

IV (Children): Preoperative sedation—0.02– 0.09 mg/kg/dose; may use smaller

doses (0.01– 0.03 mg/kg) and repeat q 20 min. Antiemetic—Single dose: 0.04–

0.08 mg/kg/dose prior to chemotherapy (not to exceed 4 mg). Multiple doses: 0.02–

0.05 mg/kg/dose q 6 hr prn (not to exceed 2 mg). Anxiety/sedation—0.02– 0.1

mg/kg (not to exceed 2 mg) q 4– 8 hr.Status epilepticus-0.1 mg/kg over 2– 5 min

(not to exceed 4 mg); may repeat with 0.05 mg/kg if needed.

IV (Infants): Preoperative sedation:—0.02– 0.09 mg/kg/dose; may use smaller

doses (0.01– 0.03 mg/kg) and repeat q 20 min. Anxiety/sedation—0.02– 0.1 mg/

kg/dose (not to exceed 2 mg) q 4– 8 hr. Status epilepticus—0.1 mg/kg over 2– 5

min (not to exceed 4 mg); may repeat with 0.05 mg/kg if needed.

IV (Neonates):Status epilepticus—0.05 mg/kg over 2– 5 min; may repeat in 10–

15 min.

NURSINGIMPLICATIONS

Assessment

● Conduct regular assessment of continued need for treatment.

● Pedi: Assess neonates for prolonged CNS depression related to inability to metabolize lorazepam.

● Geri: Assess geriatric patients carefully for CNS reactions as they are more sensitive to these effects.
Assess falls risk.

● Anxiety: Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior)
prior to and periodically throughout therapy.

● Prolonged high-dose therapy may lead to psychological or physical dependence.

Restrict amount of drug available to patient.

● Status Epilepticus: Assess location, duration, characteristics, and frequency of

seizures. Institute seizure precautions.

● Lab Test Considerations: Patients on high-dose therapy should receive routine evaluation of renal,
hepatic, and hematologic function.

● Toxicity and Overdose: If overdose occurs, flumazenil (Romazicon) is the antidote. Do not use with
patients with seizure disorder. May induce seizures.

Potential Nursing Diagnoses

Anxiety (Indications)

Risk for injury (Indications) (Side Effects)

Implementation

● Do not confuse Ativan (lorazepam) with Atarax (hydroxyzine). Do not

confuse lorazepam with alprazolam or clonazepam.

● Following parenteral administration, keep patient supine for at least 8 hr and observe closely.

● PO: Tablet may also be given sublingually (unlabeled) for more rapid onset.

● Take concentrated liquid solution with water, soda, pudding, or applesauce.

● IM: Administer IM doses deep into muscle mass at least 2 hr before surgery for

optimum effect.

IV Administration

● Direct IV: Diluent: Dilute immediately before use with an equal amount of sterile water for injection,
D5W, or 0.9% NaCl for injection. Pedi: To decrease the

amount of benzyl alcohol delivered to neonates, dilute the 4 mg/mL injection with

preservative-free sterile water for injection to make a 0.4 mg/mL dilution for IV

use. Do not use if solution is colored or contains a precipitate.Rate: Administer

at a rate not to exceed 2 mg/min or 0.05 mg/kg over 2– 5 min. Rapid IV

administration may result in apnea, hypotension, bradycardia, or cardiac arrest.

● Y-Site Compatibility: acyclovir, albumin, alemtuzumab, alfentanil, allopurinol,

amifostine, amikacin, aminocaproic acid, aminophylline, amiodarone, amphotericin B cholesteryl,

amphotericin B colloidal, amphotericin B lipiod complex, amsacrine, anakinra, anidulafungin, argatroban,
atracurium, bivalirudin, bleomycin, bumetanide, buprenorphine, bulsulfan, butorphanol, calcium
chloride, calcium

gluconate, carboplatin, carmustine, cefazolin, cefepime, cefotaxime, cefotetan,

cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol,

ciprofloxacin, cisatracurium, cisplatin, cladribine, clindamycin, cyclophosphamide, cyclosporine,

cytarabine, dactinomycin, daptomycin, dexamethasone sodium phosphate, dexmedetomidine, digoxin,
diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxorubicin, doxorubicin liposome,
doxycycline,

droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin

lactobionate, esmolol, etomidate, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim,
fluconazole, fludarabine, fosphenytoin,

furosemide, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol,

heparin, hydrocortisone sodium succinate, hydromorphone, ifosfamide, insulin,

irinotecan, isoproterenol, ketorolac, labetalol, lidocaine, linezolid, magnesium

sulfate, mannitol, mechlorethamine, melphalan, meropenem, metaraminol,

methadone, methotrexate, methyldopate, methylprednisolone sodium succinate,

metoclopramide, metoprolol, metronidazole, micafungin, midazolam, milrinone,

mitoxantrone, morphine, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine,

nitroglycerin, nitroprusside, norepinephrine, octreotide, oxaliplatin, oxytocin, paclitaxel, palonosetron,
pamidronate, pancuronium, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine,
piperacillin/

tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine,

propofol, propranolol, quinupristin/dalfopristin, ranitidine,

remifentanil, rituximab, sodium acetate, sodium bicarbonate, sodium phosphates, streptozocin,

succinylcholine, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline,
tirofiban, tobramycin, trastuzumab, trimethoprim/sulfamethoxazole, vancomycin, vasopressin,
vecuronium, verapamil,

vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid.

● Y-Site Incompatibility: aldesleukin, ampicillin, ampicillin/sulbactam, aztreonam, dantrolene,

doxacurium, fluorouracil, hydralazine, idarubicin, imipenem/cilastatin, meperidine, omeprazole,
ondansetron, pantoprazole, phenytoin,

potassium phosphates, rocuronium, sargramostim, sufentanil.

Patient/Family Teaching

● Instruct patient to take medication exactly as directed and not to skip or double up

on missed doses. If medication is less effective after a few weeks, check with health

care professional; do not increase dose.

● Advise patient that lorazepam is usually prescribed for short-term use and does
not cure underlying problem.

● Advise patient to decrease lorazepam dose gradually to minimize withdrawal

symptoms; abrupt withdrawal may cause tremors, nausea, vomiting, and abdominal and muscle cramps.

● Teach other methods to decrease anxiety, such as increased exercise, support

groups, relaxation techniques. Emphasize that psychotherapy is beneficial in addressing source of anxiety
and improving coping skills.

● May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring
alertness until response to medication is known.

● Caution patient to avoid taking alcohol or other CNS depressants concurrently with

this medication.

● Instruct patient to contact health care professional immediately if pregnancy is

planned or suspected.

● Emphasize the importance of follow-up exams to determine effectiveness of the

medication.

Evaluation/Desired Outcomes

● Increase in sense of well-being.

● Decrease in subjective feelings of anxiety without excessive sedation.

● Reduction of preoperative anxiety.

● Postoperative amnesia.

● Improvement in sleep patterns.