What to Know About Ativan (Lorazepam)

Ativan (lorazepam) is a prescription medication used for the short-term treatment of anxiety disorders and symptoms of anxiety. It is in a class of drugs called benzodiazepines, which bind to gamma-aminobutyric acid (GABA) receptors in the brain to slow down the central nervous system (CNS), causing drowsiness or calming effects.

Ativan comes in tablet form and is available as a generic. Ativan Injection is another form of the drug that is used in healthcare settings to help treat status epilepticus (prolonged seizures) or as a preanesthetic medication to calm and sedate a patient before surgery and anesthesia. Ativan Injection is administered into a vein or a muscle.

There is also the lorazepam brand Lorazepam Intensol that comes in an oral concentrate that you mix with fluids and drink.

Uses

Oral Ativan (lorazepam) is approved for the short-term management of anxiety disorders, such as generalized anxiety disorder (GAD), or immediate relief of anxiety symptoms in adults and children 12 and older.

It can also be prescribed on a short-term basis for anxiety-related insomnia or anxiety associated with depression.

In hospital settings, Ativan Injection can be used as a treatment for potentially life-threatening seizures and is often given to stop status epilepticus or to prevent a seizure in a patient who has been having multiple seizures while hospitalized. When given for seizures, an injection into a vein is preferred. An injection into muscle is only recommended if IV access is unavailable and the medication must be given.

Ativan Injection is also approved as a sedative prior to general anesthesia and surgery. It can be injected into a muscle or given intravenously for this purpose.

However, research suggests that using Ativan before surgery may not reliably improve the patient's experience and can prolong recovery.

A randomized control trial that compared patients given lorazepam prior to elective surgeries with those given a placebo or no medication concluded that lorazepam did not improve the patient's experience. Use of the drug was also associated with longer times spent on mechanical ventilation and cognitive recovery.

Off-Label Uses

Ativan is also sometimes prescribed for alcohol withdrawal symptoms and to try to reduce withdrawal complications, which can include seizures.

It can also be used in the treatment of schizophrenia symptoms, such as agitation, and to help decrease nausea and vomiting during chemotherapy.

In hospitals, Ativan may also be used after surgery to improve sleep, decrease agitation, improve symptoms of postoperative delirium, and enhance relaxation.

In the critical care areas, Ativan may be given to help the patient tolerate a ventilator or a bedside procedure. In this case, the medication may be given periodically as an IV injection or may be given continuously as an IV drip. 

Before Taking

First-line treatments for anxiety disorders are psychotherapy, medications approved for long-term use, or both.

Cognitive behavioral therapy is a form of psychotherapy that is often used for anxiety. It involves helping a patient examine and analyze their thoughts and feelings, especially those related to triggering or reducing anxiety. It may also involve practicing techniques that can be utilized in scenarios that commonly lead to anxiety.

Selective serotonin reuptake inhibitors (SSRIs), such as Zoloft (sertraline) or Paxil (paroxetine), or serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Cymbalta (duloxetine) or Effexor (venlafaxine), are first-line medications used for anxiety disorders. SSRIs and SNRIs target the neurotransmitter serotonin, making it more available in the body and decreasing feelings of anxiety.

Benzodiazepines, such as Ativan or Xanax (alprazolam), are considered a second-line or adjunct medication for GAD and other anxiety disorders when initial treatments are not sufficient either alone or at all.

Benzodiazepines act quickly to address symptoms, such as muscle tension and restlessness, so they may be prescribed for use in select situations (e.g., air travel) or as an adjunct medication until a first-line therapy starts becoming effective.

For example, SSRIs may take several months to reach their full effectiveness. If you are prescribed Ativan while starting an SSRI, you will be slowly weaned off Ativan as the SSRI takes effect.

Precautions and Contraindications

Ativan is a federally controlled substance because it can be abused or lead to addiction. Due to these and other health risks, your healthcare provider will want to do a thorough mental and physical health history before prescribing Ativan to you.

Medical circumstances that can make taking Ativan risky or prohibit its use include:

• Allergy or hypersensitivity: Do not take Ativan if you have a known allergy or hypersensitivity to benzodiazepines or any of the medication's inactive ingredients.
• Acute narrow-angle glaucoma: Do not take benzodiazepines if you have this eye emergency since there may be a risk of increased eye pressure.
• Pregnancy: There is evidence that Ativan could cause harm to a fetus. Your healthcare provider can help you evaluate the benefits vs. risks of use. Prolonged use during pregnancy may result in an infant experiencing withdrawal after birth.
• Lactation: Do not take Ativan while breastfeeding, as it can be passed to an infant through breast milk, possibly causing sedation and impaired breathing.
• Personal or family history of addiction or substance abuse: Risks for addiction, abuse, and misuse increase for those who are prone to addiction. Your healthcare provider may opt not to prescribe Ativan based on these added risks, or counseling and careful monitoring may be needed during treatment.
• History of depression or suicidal ideation: Pre-existing depression may emerge or worsen during use of benzodiazepines. Your healthcare provider may opt not to prescribe Ativan due these risks, or you may need careful monitoring and antidepressant therapy while taking this medication.
• Compromised respiratory function: Those with conditions such as chronic obstructive pulmonary disease (COPD) or sleep apnea may have an increased risk of serious respiratory side effects on Ativan.

Lorazepam can interact with other medications that may lead to serious or life-threatening adverse reactions. Always discuss all medications with your healthcare provider.

Other Benzodiazepines

Other common types of benzodiazepines that may be prescribed for anxiety include:

• Xanax (alprazolam)
• Klonopin (clonazepam)
• Valium (diazepam)
• Librium (chlordiazepoxide)

Your healthcare provider can help evaluate which benzodiazepine may be the best option in your case.

Dosage

Ativan may be taken every day at regular times or on an as-needed basis (with daily dosage requirements). It is typically prescribed for two to four weeks at a time and is not approved for use longer than four months. Take this medication specifically as prescribed by your healthcare provider.

Ativan comes in 0.5 milligram (mg), 1 mg, and 2 mg tablets. A typical dosage is 2 to 6 mg per day given in two or three divided doses, but the dosages can vary from 0.5 mg per day up to a maximum of 10 mg per day. Due to dependency and addiction risks, Ativan is given at the smallest effective dose for the shortest duration possible.

For anxiety disorders, most patients are prescribed a starting dose of 2 to 3 mg per day that is split into two or three doses. The largest dose is typically taken before bedtime.

For insomnia due to anxiety or short-term situational stress, a single daily dose of 2 to 4 mg may be taken at bedtime. 

Oral doses are typically higher than injection doses given by a healthcare provider. An individual who requires 0.5 mg when given the IV form of the drug may receive 1 mg or more if they need to take the medication by mouth.

All listed dosages are according to the drug manufacturer. Check your prescription and talk to your healthcare provider to make sure you are taking the right dose for you.

Modifications

Adolescents and older adults are more likely to be sensitive to the medication or to have paradoxical reactions to it, meaning Ativan causes rather than relieves agitation and anxiety. In these groups, the medication should be given at very low staring doses.

How to Take and Store

Ativan can be taken with or without food. If you miss a dose, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose. Do not take two doses or more than your prescribed daily dose.

Store the medication at room temperature (ideally 77 degrees F). If necessary, Ativan can be taken on excursions so long as it is kept in temperatures ranging from from 59 to 86 degrees F.

Side Effects

Ativan is usually well tolerated, but it can sometimes lead to serious side effects.

Common

The most common side effect associated with Ativan is sedation. While this can be problematic in some ways, it is often a desired effect given the symptoms the medication works to treat.

Other common side effects include:

• Dizziness
• Weakness
• Unsteadiness

Sedation and unsteadiness are more common in older adults who take Ativan.

This medication can also cause amnesia, especially in higher doses. When given in a medical setting prior to a procedure, the patient may remember little or nothing of the time immediately following the administration of the dose.

Severe

In rare cases, Ativan can result in paradoxical effects that amplify anxiety or cause very serious and life-threatening side effects, such as respiratory depression and allergic reactions—especially at high doses.

Seek urgent medical attention if you experience any of the following side effects:

• Shortness of breath
• Slurred speech
• Increased irritability
• Restlessness
• Feeling depressed/lack of interest in life (pre-existing depression may emerge or worsen while taking Ativan) 
• Suicidal thoughts
• Swelling of your face, tongue, or throat
• Changes in eye function or visual disturbances
• Memory impairment

Warnings and Interactions

Ativan is not a long-term solution. Your healthcare provider can help you explore other options for managing your anxiety. If you suspect you are becoming dependent on Ativan or taking more than you're supposed to in order to get the desired effect, contact your healthcare provider immediately.

Some people who take Ativan may develop leukopenia, a low white blood cell count that can make it harder for the immune system to fight infections. Elevated lactate dehydrogenase (LDH), an enzyme that can indicate tissue damage in the liver and other major organs, may also occur.

While you are on Ativan, your healthcare provider may have you come in for several appointments to evaluate your dosage and to run blood tests, such as those to check white blood cell counts and LDH levels.

Careful monitoring is needed for those with liver disease and hepatic encephalopathy, which can appear as confusion or difficulty processing thoughts, while on benzodiazepines.

Elderly adults and those taking Ativan for prolonged periods may also need frequent monitoring for signs of upper gastrointestinal GI problems since preliminary research suggests that lorazepam may affect the esophagus.

Ativan can lead to sedation so you should not drive or operate machinery after taking the medication.

Due to a risk of decreased breathing, Ativan should not be given with other central nervous system (CNS) depressants without proper monitoring by a healthcare provider or in a hospital setting. The combination may lead to an increased risk of breathing problems, coma, and death. Other CNS depressants include:

• Other benzodiazepines and anti-anxiety medications
• Opioid pain medications, such as morphine, OxyContin (oxycodone), Vicodin (hydrocodone), and ConZip (tramadol)
• Sleeping pills, such as Ambien (zolpidem)
• Tricyclic antidepressants
• Sedative antihistamines, such as Benadryl (diphenhydramine)
• Anticonvulsant
• Anesthetics
• Barbituates
• Antipsychotics

Alcohol is also a CNS depressant and should not be taken with Ativan.

Other drugs that can interact with Ativan include:

• Clozaril (clozapine): Taking Ativan with this antipsychotic medication used for schizophrenia can lead to excessive sedation, excessive salivation, hypotension (low blood pressure), impaired coordination, delirium, and respiratory arrest in rare cases. Careful monitoring is needed and dosage adjustments of either medication may be required.
• Valproate anticonvulsants: These medications used for seizures or bipolar disorder—e.g., Depacon (valproate sodium), Depakote (divalproex sodium), or valproic acid—can increase blood levels of Ativan and decrease your body's clearance of the drug. The dosage of Ativan should be reduced by about 50%.
• Probalan (probenecid): Taking this gout mediction with Ativan can result in a more rapid onset or prolonged effect of Ativan. The dosage of Ativan should be reduced by about half.
• Theolair (theophylline) or aminophylline: These medications used for asthma and other lung diseases may reduce the sedative effects of benzodiazepines.