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Lorazepam is a benzodiazepine medication approved by the US Food and Drug Administration (FDA) for short-term relief of anxiety symptoms associated with anxiety disorders, anxiety-related insomnia, anesthesia premedication in adults to relieve anxiety or induce sedation or amnesia, and treatment of status epilepticus. Lorazepam is favored in inpatient settings for its rapid onset of action (1-3 minutes intravenously). Off-label uses for lorazepam include rapid tranquilization of agitated patients, alcohol withdrawal delirium and syndrome, insomnia, panic disorder, delirium, chemotherapy-associated anticipatory nausea and vomiting (adjunct or breakthrough), vertigo, and psychogenic catatonia. Lorazepam is used in various clinical practices and is often compared with other benzodiazepines. Clinicians from several specialties and at different levels of practice utilize it in acute, short-term, and long-term settings. This activity reviews lorazepam, including its mechanism of action, adverse event profiles, and monitoring, and identifies potential drug-drug interactions through its pharmacokinetics. This activity allows participating clinicians to make decisions and optimize dosage regimens while minimizing the adverse reactions of the drug. In addition, the interprofessional healthcare team, comprising clinicians, pharmacists, and therapists, works together to provide appropriate treatment for patients with psychiatric conditions. Objectives: Identify appropriate indications for lorazepam use based on patient presentation and clinical guidelines. Implement appropriate monitoring protocols to assess patient response and potential adverse reactions to lorazepam therapy. Select alternative treatment options or adjust lorazepam dosage based on individual patient characteristics and treatment goals. Collaborate with interprofessional healthcare teams, including pharmacists and therapists, to ensure comprehensive patient care and treatment planning. Access free multiple choice questions on this topic.

Signs and Symptoms of Overdose Lorazepam can cause CNS and respiratory depression in overdose, potentially leading to hypotension, ataxia, confusion, coma, extreme drowsiness, muscle weakness, and death.[21] Concurrent use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.[39] Therefore, the prescribing of benzodiazepines and opioids together should be reserved for patients with inadequate alternative treatment options. The dosage and duration of lorazepam must be limited based on the indication, and patients require surveillance for signs and symptoms of respiratory depression. While lorazepam, similar to other benzodiazepines, is rarely associated with elevated serum ALT, clinically apparent liver injury from lorazepam is infrequent.[40] The clinical pattern of acute liver injury from benzodiazepines is typically cholestatic. Management of Overdose Flumazenil is an antidote for benzodiazepine toxicity.[41] Flumazenil competes with benzodiazepines for binding at the GABA/benzodiazepine receptor complex. However, abrupt awakening following administration can lead to dysphoria, agitation, and increased adverse effects.[42] In patients undergoing chronic benzodiazepine therapy, the sudden interruption of benzodiazepine antagonism by flumazenil may induce benzodiazepine withdrawal, including seizures. Notably, flumazenil has minimal effects on benzodiazepine-induced respiratory depression, and appropriate ventilatory support should be available when treating acute benzodiazepine overdose.[43] A recent case report detailed a severe lorazepam overdose with absent corneal, oculocephalic, and oculovestibular reflexes; however, the patient recovered after receiving 0.25 mg IV flumazenil.[44]

Similar to other benzodiazepine medications, lorazepam can be highly addictive. Therefore, a collaborative approach involving an interprofessional healthcare team is essential for prescribing and managing these medications. This team typically includes clinicians (MDs, DOs, NPs, and PAs), psychiatrists, nursing staff, and pharmacists, all of whom should remain vigilant for signs of misuse or adverse effects. By adopting this approach, the team can prevent misuse and unintended adverse events, ultimately optimizing therapy. High doses or prolonged durations of lorazepam require careful consideration, especially in patients with a history of substance use disorder or concurrent opioid prescriptions. Managing such cases necessitates an interprofessional healthcare team involving nurses, pharmacists, and various specialist clinicians. This team should diligently monitor for signs of abuse, diversion, or concurrent use with other prescription or non-prescription sedative medications. Prescribers and pharmacists must closely monitor treatment, offer patient education, and exercise vigilance when prescribing benzodiazepines such as lorazepam. Additionally, the prescription drug monitoring program can help identify potential misuse of lorazepam.[45] During a lorazepam shortage in 2022, interdisciplinary collaboration of healthcare teams led to alternative treatment recommendations, primarily involving the use of midazolam in palliative care. Benzodiazepine utilization notably decreased during the shortage but reverted to baseline levels after its resolution. Fortunately, no patient safety events occurred, and care experiences remained unaffected. This collaborative effort effectively conserved lorazepam for patients lacking alternatives while ensuring effective management of palliative care needs.[46] Moving forward, the interprofessional healthcare team should utilize 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 practices are achievable only through interprofessional treatment overseen by clinicians, pharmacists, and nurses.