Lorazepam should be used with caution in patients with compromised respiratory function (e.g., COPD, sleep apnea syndrome).
Pre-existing depression may emerge or worsen during use of benzodiazepines including lorazepam. The use of benzodiazepines may unmask suicidal tendencies in depressed patients and should not be used without adequate antidepressant therapy.
Paradoxical reactions have been occasionally reported during benzodiazepine use (See ADVERSE REACTIONS). Such reactions may be more likely to occur in children and the elderly. Should these occur, use of the drug should be discontinued.
Use in the Elderly: Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated with very low initial doses in these patients, depending on the response of the patient, in order to avoid over sedation or neurological impairment.
For elderly and debilitated patients reduce the initial dose by approximately 50% and adjust the dosage as needed and tolerated.
Dependence Liability: Ativan (lorazepam) should not be administered to individuals prone to drug abuse. Lorazepam may have abuse potential, especially in patients with a history of drug and/or alcohol abuse.
Caution should be observed in patients who are considered to have potential for psychological dependence. It is suggested that the drug should be withdrawn gradually if it has been used in high dosage.
The use of benzodiazepines, including lorazepam, may lead to physical and psychological dependence. The risk of dependence increases with higher doses and longer term use and is further increased in patients with a history of alcoholism or drug abuse or in patients with significant personality disorders. The dependence potential is reduced when lorazepam is used at the appropriate dose for short-term treatment. In general, benzodiazepines should be prescribed for short periods only (e.g., 2-4 weeks). Continuous long-term use of lorazepam is not recommended.
Use in Mental and Emotional Disorders: Ativan (lorazepam) is not recommended for the treatment of psychotic or depressed patients. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patients suspected of having psychotic tendencies.
As with other anxiolytic-sedative drugs, lorazepam should not be used in patients with non-pathological anxiety. These drugs are also not effective in patients with characterological and personality disorders or those with obsessive-compulsive neurosis.
When using Ativan, it should be recognized that suicidal tendencies may be present and that protective measures may be required.
Use in Patients with Impaired Renal or Hepatic Function: Since the liver is the most likely site of conjugation of lorazepam and since excretion of conjugated lorazepam (glucuronide) is a renal function, the usual precaution of carefully titrating the dose should be taken, should Ativan be used in patients with mild to moderate hepatic or renal disease. In patients for whom prolonged therapy with Ativan is indicated, periodic blood counts and liver function tests should be carried out.
When lorazepam is used in patients with mild to moderate hepatic or renal disease, the lowest effective dose should be considered since drug effect may be prolonged.
Dosage for patients with severe hepatic insufficiency should be adjusted carefully according to patient response. Lower doses may be sufficient in such patients.
As with all benzodiazepines, the use of lorazepam may worsen hepatic encephalopathy; therefore, lorazepam should be used with caution in patients with severe hepatic insufficiency and/or encephalopathy.