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Medication Overview for Ativan (Lorazepam) as an Anxiety Medication
Ativan, also known as its generic name lorazepam, belongs to a class of drugs known as benzodiazepines that are used as anxiety medication. Benzodiazepines work by slowing down the nervous system and brain, thus helping to relieve symptoms of anxiety, other mental illnesses, and seizures. Due to their mechanism of action, they have the below effects:
- Anxiolytic. Benzodiazepines help to relieve feelings of anxiety.
- Hypnotic. Hypnotic drugs induce feelings of fatigue and drowsiness, helping with sleep.
- Sedative. Benzodiazepines cause sedation, quieting the mind and body.
Benzodiazepines like Ativan are considered controlled drugs, as they can have dangerous side effects and some abuse potential. Nevertheless, they are effective in treating a variety of conditions and are generally well-tolerated when used as directed as anxiety medication.
Medical Indications for Ativan (Lorazepam)
Ativan was approved by the Food and Drug Administration (FDA) in 1977. It is indicated for short-term treatment of anxiety-related symptoms such as anxiety disorders, insomnia, and premedication for anesthesia. It is also approved for status epilepticus, a seizure disorder.
There are also several off-label indications for Ativan, meaning it is prescribed for uses not approved by the FDA. These include alcohol withdrawal, insomnia, delirium, panic disorder, chemotherapy-related nausea, vomiting, vertigo, agitation, and more.
Dosage and Administration
Ativan is available several dosage forms, including:
- Tablets: 0.5, 1, and 2 mg tablets
- Oral solution: 2 mg/mL
- Extended-release capsule: 1, 2, and 3 mg
- Intravenous (IV)/intramuscular (IM): 2 mg/mL, 4 mg/mL
The dose of Ativan will depend on what dosage form you are using as well as what you are taking it for. Your healthcare provider will instruct you on how to take your medication; however, typical dosing for oral formulations is as follows:
- Anxiety medication: The usual starting dose is 2 to 3 mg by mouth, taken two to three times daily. The maximum dose is 10 mg daily.
- Insomnia because of stress or anxiety: Individuals under the age of 65 can take between 0.5 to 2 mg by mouth before bed. Individuals over the age of 65 can take 0.5 to 1 mg before bed.
- Nausea and vomiting due to chemotherapy: Patients can take 0.5 to 2 mg every six hours as needed by mouth. It can also be administered IV or under the tongue.
There is additional dosing for other indications when given IV or IM. Be sure to always take your medication as directed by your doctor.
Potential Side Effects of Anxiety Medication
Ativan, an anxiety medication, can cause many side effects. These include fatigue, weakness, nausea, diarrhea, constipation, dizziness, blurred vision, unsteadiness, appetite changes, differences in sex drive or sexual function, excitement, or restlessness. It can also cause more serious side effects, which include:
- Difficulty speaking
- Irregular heartbeat
- Allergy symptoms (e.g., rash, wheezing, shortness of breath, swelling)
- Tremor
- Shuffling walk
- Yellow skin and/or eyes
Any of these effects could be indicative of a more serious issue. Thus, seek medical attention immediately if you experience any of these adverse events.
Precautions and Contraindications of Ativan (Lorazepam)
As mentioned, Ativan can cause serious side effects requiring prompt intervention and treatment. Thus, you should use caution when taking Ativan and be aware of the potential risks outlined below:
- Concomitant use with opioids. Taking any type of benzodiazepine with an opioid medication can cause respiratory depression. Respiratory depression occurs when the lungs do not function properly, resulting in an imbalance of oxygen and carbon dioxide in the body. Taking these two medications together can also cause coma and death. Thus, these should only be prescribed together if absolutely necessary when other alternative therapies do not work.
- Addiction. Taking benzodiazepines such as Ativan causes physical and psychological dependence. The chance of this is higher with increased doses, long-term duration of use, and with patients who have a history of substance use disorder. To avoid addiction, Ativan should be taken only for short-term treatment at the correct dose and only when clinically indicated. It should be used with caution in people with an addiction history.
- Depression. Taking benzodiazepines may cause the emergence of pre-existing depression or worsening of existing depression. Thus, they are not recommended in individuals with primary depressive disorder or psychosis.
- Withdrawal. Stopping Ativan or any benzodiazepine suddenly can cause withdrawal. Withdrawal symptoms are widespread and include signs such as sweating, anxiety, tension, nausea, vomiting, diarrhea, headache, depression, irritability, panic attacks, stomach cramps, confusion, sweating, hallucinations/delirium, seizures, dizziness, and more.
Who Should Take Caution When Using Ativan as an Anxiety Medication
In addition, Ativan should be used with caution in the following types of patients:
- Those with depression. Benzodiazepines should only be used in patients who are stabilized on antidepressant treatment due to the depressive effects of Ativan.
- The elderly. Older individuals are more sensitive to Ativan’s sedative effects, which can be dangerous. Thus, seniors should start on lower doses and be monitored regularly.
- Those with impaired respiratory function. This includes patients with chronic obstructive pulmonary disease (COPD) and sleep apnea.
Ativan should not be taken if a patient has a history of allergy with benzodiazepines. Additionally, Ativan is contraindicated in narrow-angle glaucoma.
Interactions of Ativan (Lorazepam)
Ativan interacts with other drugs, and thus should be avoided or used with caution with certain medications. As previously mentioned, taking both benzodiazepines and opioids increases one’s risk for respiratory depression. Thus, the dose and duration of therapy for both benzodiazepines and opioids should be limited, and these patients should be monitored closely.
Ativan also has the potential to interact with other medications and substances that are CNS depressants. These include things like alcohol, sedatives, antidepressants, anticonvulsants, antipsychotics, barbiturates, and more.
More specific drugs that Ativan interacts with include clozapine, valproate, probenecid, theophylline, or aminophylline. Always let your healthcare provider know what medications you are on before starting therapy. They can help to check for drug interactions, and if interactions exist, adjust your dose or therapy as needed.
Effectiveness and Expectations of Ativan as an Anxiety Medication
When taken correctly, Ativan can be very effective in treating certain conditions. One four-week study evaluated Ativan treatment in 68 adults with anxiety and related symptoms. Individuals taking Ativan had significantly better results when compared with individuals taking placebo when it came to anxiety symptoms.
Other studies have assessed Ativan in helping with sleep, with one such study administering 2 mg of Ativan over the course of seven nights. Findings demonstrated that it was effective in causing sleeping and helping participants to stay asleep. Some participants experienced side effects such as confusion and memory impairment.
Long-Term Use and Monitoring of Ativan (Lorazepam)
Long-term use of benzodiazepines as an anxiety medication is not recommended. The FDA has only approved Ativan in particular, for short-term treatment (less than four months). This is because long-term use of benzodiazepines poses a risk of dependence and addiction. If using Ativan, patients should start at the lowest dose possible for as long as possible.
Providers should monitor for blood pressure, heart rate, cardiovascular status, and respiratory status to prevent adverse events. Providers can also use the Clinical Institute Withdrawal Assessment for Alcohol – Revised (CIWA-Ar) to monitor and adjust a patient’s Ativan dose.
Alternatives and Complementary Therapies
Because of the side effects and dependence potential with Ativan and other benzodiazepines, some individuals may look to other options to help manage their anxiety symptoms and other conditions. Thankfully, several alternative anxiety medications have fewer side effects and are not addictive. These include:
- Selective serotonin reuptake inhibitors (SSRIs). SSRIs can treat both anxiety and depression by acting on serotonin, a chemical messenger in the brain implicated in mood and anxiety. Some SSRIs include Lexapro (escitalopram), Zoloft (sertraline), Celexa (citalopram), and Prozac (fluoxetine).
- Selective norepinephrine reuptake inhibitors (SNRIs). SNRIs work similarly to SSRIs, but also affect norepinephrine, which is both a neurotransmitter and hormone. Some SNRIs include Effexor XR (venlafaxine), Cymbalta (duloxetine), and Pristiq (desvenlafaxine).
- Beta-blockers. Beta-blockers are commonly used to treat high blood pressure, but they can also be used off-label to treat the more physical effects associated with anxiety.
- Antihistamines. An antihistamine known as Vistaril (hydroxyzine) has been shown to be effective in treating anxiety as needed.
Additional Therapies for Anxiety
In addition to prescription medication, there are several non-pharmacologic options that you can utilize both alone and in combination with medication to help manage anxiety. For example, cognitive behavioral therapy (CBT) is a method used by therapists to instruct on how to approach negative thought patterns to prevent anxiety symptoms.
Frequently Asked Questions (FAQs) About Ativan (Lorazepam)
Will I experience withdrawal when stopping Ativan as an anxiety medication?
If you have been on Ativan for an extended period, you may experience withdrawal symptoms when stopping therapy. Withdrawal symptoms include headache, increased blood pressure, sweating, confusion, irritability, anxiety, nausea, vomiting, tremors, changes to heart rate, and more.
How do I prevent withdrawal symptoms with Ativan?
If you have been on Ativan for a prolonged period of time but plan to stop therapy, it is best to taper your dose to avoid withdrawal. This will involve lowering your dose every few weeks or months. Your doctor can help you develop this schedule to lower your dose over time, eventually stopping altogether successfully.
Resources
- https://my.clevelandclinic.org/health/treatments/24570-benzodiazepines-benzos
- https://www.ncbi.nlm.nih.gov/books/NBK532890/#:~:text=Lorazepam%20is%20FDA%2Dapproved%20for,and%20treatment%20of%20status%20epilepticus.
- https://medlineplus.gov/druginfo/meds/a682053.html
- https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017794s044lbl.pdf
- https://pubmed.ncbi.nlm.nih.gov/30763/
- https://pubmed.ncbi.nlm.nih.gov/3960963/