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Contraindications/Precautions
Contraindicated in: Hypersensitivity; Cross-sensitivity with other benzodiaze-
1
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
IM
IV
15–60 min
30–60 min
15–30 min
1–6 hr
1–2 hr†
15–20 min
8–12 hr
8–12 hr
8–12 hr
†Amnestic response
⫽ Canadian drug name.
Plate # 0-Composite
⫽ Genetic Implication.
pines 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
other sedative/hypnotics including other benzodiazepines. Maypthe efficacy of levodopa. Smoking mayqmetabolism andpeffectiveness. Valproate and canqlevels (pdose by 50%). Oral contraceptives mayplevels.
Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile 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.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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● Anxiety: Assess degree and manifestations of anxiety and mental status (orienta-
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.
● Prolonged high-dose therapy may lead to psychological or physical dependence.
tion, mood, behavior) prior to and periodically throughout therapy.
NURSING IMPLICATIONS
Assessment
● Conduct regular assessment of continued need for treatment.
● Pedi: Assess neonates for prolonged CNS depression related to inability to metab-
olize lorazepam.
● Geri: Assess geriatric patients carefully for CNS reactions as they are more sensi-
tive to these effects. Assess falls risk.
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 ob-
serve 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 ster-
ile 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,
䉷 2015 F.A. Davis Company
CONTINUED
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Patient/Family Teaching
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● Instruct patient to take medication exactly as directed and not to skip or double up
CONTINUED
LORazepam
●
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.
⫽ Canadian drug name.
⫽ Genetic Implication.
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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
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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.
Why was this drug prescribed for your patient?
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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