lorazepamlor-az-e-pam

Apo-Lorazepam, Ativan, Novo-Lorazem, Nu-Loraz

Classification
Therapeutic: Pharmacologic:

Schedule IV

Pregnancy Category D

Copyright © 2009 by F.A. Davis Company

Indications

Anxiety disorder (oral)
Preoperative sedation (injection)
Decreases preoperative anxiety and provides amnesia
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

Pharmokinetics

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 min1–6 hr8–12 hr
IM 30–60 min1–2 hr†8–12 hr
IV 15–30 min15–20 min8–12 hr
†Amnestic response

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: Use in pregnancy and lactation may cause CNS depression, flaccidity, feeding difficulties, hypothermia, seizures, and respiratory problems in the neonate
Lactation: Recommend to discontinue drug or bottle-feed
Use Cautiously in: Severe hepatic/renal/pulmonary impairment
Myasthenia gravis
Depression
Psychosis
History of suicide attempt or drug abuse
COPD
Sleep apnea
Pedi: Use cautiously in children under 12 yr. In ↑ 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
OVERDOSEAdminister Flumazenil (do not use with patients with seizure disorder. May induce seizures

Adverse Reactions/Side Effects*

*CAPITALS indicate life threatening; underlines indicate most frequent.

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 onlyapnea, 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
May ↓ the efficacy of levodopa
Smoking may ↑ metabolism and ↓ effectiveness
Valproate can ↑ serum concentrations and ↓ clearance (↓ dose by 50%)
Probenecid may ↓ metabolism of lorazepam, enhancing its actions (↓ dose by 50%)
Oral contraceptives may increase clearance and decrease concentration of lorazepam
Drug–Natural: Concomitant use of kava, valerian or, chamomile can ↑ CNS 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, increased as needed
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
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
and adolescents > 18 yrAnxiety — 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
and debilitated patients0.5 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)
Preoperative sedation—0.02–0.09 mg/kg/dose
Preoperative sedation—0.02–0.09 mg/kg/dose
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)
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
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
Status epilepticus-0.05 mg/kg over 2–5 min; may repeat in 10–15 min

Availability (generic available)

Tablets: 0.5 mg, 1 mg , 2 mg
Concentrated oral solution: 0.5 mg/5 ml, 2 mg/ml
Sublingual tablets 0.5 mg 1 mg2 mg
Injection: 2 mg/ml, 4 mg/ml

NURSING IMPLICATIONS

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. Ass falls risk
    AnxietyAssess 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 EpilepticusAssess 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.
Potential Nursing Diagnoses Anxiety (Indications)
Implementation
  • Do not confuse Ativan (lorazepam) with Atarax (hydroxyzine).
  • Following parenteral administration, keep patient supine for at least 8 hr and observe closelyPO: 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 useDo not use if solution is colored or contains a precipitate
    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
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    • 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 taper lorazepam by 0.05 mg q 3 days to decrease 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 sedationReduction of preoperative anxiety
      Postoperative amnesia
      Improvement in sleep patterns.