lorazepam

General Information

Lorazepam is a short-to-intermediate acting benzodiazepine used for anxiety and insomnia due to anxiety or stress. In psychiatric practice it is also a cornerstone medication for catatonia evaluation and treatment.

Unlike many benzodiazepines, lorazepam is metabolized via glucuronidation (not CYP), which can simplify interaction management, but additive sedation and respiratory depression risks remain central.

In catatonia pathways, rapid improvement after a “lorazepam challenge” supports the diagnosis and should trigger a broader care plan (medical evaluation, supportive care, and early ECT readiness if response is incomplete) rather than an indefinite standing benzodiazepine order.

Use is generally avoided or approached with extreme caution in older adults, untreated sleep apnea/COPD, and with concurrent opioids or alcohol; sedation, falls, and respiratory compromise can outweigh benefit.

The lorazepam compare view, the lorazepam evidence feed, and the lorazepam print page support side-by-side review when aligning calming strategies with catatonia pathways and safety planning.

Lorazepam is often reserved for targeted, time-limited indications (catatonia, severe acute anxiety) with explicit taper plans and frequent follow-up; open-ended chronic use is generally avoided. Lorazepam’s non-CYP metabolism can simplify interaction management, but the core safety concerns remain sedation, falls, and respiratory depression—short prescriptions, documented goals/stop dates, and reassessment at renewal are common safeguards.

Mechanism of Action

Refer to the Glossary entry on Neurotransmitters for background on receptor systems involved in serious mental illness.

Positive allosteric modulator of GABA-A receptors that increases inhibitory neurotransmission.

Produces anxiolysis, sedation, and anticonvulsant effects; rapid onset makes it useful in catatonia pathways.

Lorazepam treats symptoms but does not address underlying anxiety drivers; psychotherapy and SSRI/SNRI-based plans are commonly paired when ongoing anxiety is present.

• GABA-A receptor facilitation (benzodiazepine class).
• Minimal direct activity at serotonergic, dopaminergic, or adrenergic receptors.

Metabolism and Pharmacokinetics

• Rapidly conjugated to lorazepam glucuronide (inactive) and excreted in urine.
• Mean plasma half-life of unconjugated lorazepam is ~12 hours (label).
• Not metabolized by CYP enzymes; fewer CYP-mediated interactions than many benzodiazepines.
• Older adults and medically ill patients can have exaggerated sedation and falls; lower starting doses, minimizing sedative stacking, and reassessment of next-day function are common.

Dosing and Administration

• Anxiety (label ranges vary): typically 1–3 mg/day in divided doses; titration is typically cautious based on sedation and fall risk.
• Insomnia due to anxiety/stress (label varies): bedtime dosing; avoid chronic nightly use is generally avoided.
• Catatonia (off label): lorazepam challenge and maintenance strategies vary by protocol; follow-up is often frequent, with escalation to ECT pathways when needed.
• Gradual tapering is typically used after courses >2–4 weeks; abrupt discontinuation increases withdrawal and seizure risk.
• Nightly use as a sleep medication is generally avoided; if insomnia is the primary complaint, underlying drivers and insomnia-specific strategies are often prioritized.
• When extended-release products are used, capsules are not crushed or split, and “as needed” redosing on top of scheduled dosing is generally avoided.

Monitoring & Labs

• Functional benefit and safety are reassessed at each renewal; open-ended continuation without documented goals is generally avoided.
• Sedation, falls, and driving impairment are monitored—especially in older adults and when other CNS depressants are present.
• For catatonia, follow-up is often frequent, with coordinated escalation pathways (medical evaluation and ECT readiness when response is incomplete).
• If discontinuing after more than brief use, gradual tapering and monitoring for withdrawal symptoms and rebound anxiety are typical.

Sources: FDA/DailyMed label; guideline statements.

Adverse Effects

Interactions

• Additive CNS and respiratory depression with opioids, alcohol, antihistamines, and sedating antipsychotics.
• Valproate and probenecid can reduce lorazepam clearance via glucuronidation inhibition; lower dosing and closer sedation monitoring may be needed.
• Even without CYP metabolism, lorazepam still carries additive impairment with other sedatives (Z-drugs, gabapentinoids, muscle relaxants); stacking hypnotics is generally avoided when feasible.

Other Useful Information

• Indication, time horizon, and taper plan are commonly documented at initiation; ongoing need is revisited frequently.
• For catatonia, coordinate escalation pathways (benzodiazepine response monitoring, ECT readiness, medical evaluation).
• Prescription monitoring data and substance use risk are commonly reviewed when benzodiazepines are used.
• Short prescriptions with planned follow-up are common, and “automatic” refills are generally avoided; when discontinuing, gradual tapering and monitoring for withdrawal symptoms and functional relapse are typical.

References

1. Ativan (lorazepam) prescribing information — DailyMed (2025)
2. ASAM guideline on benzodiazepines — Journal of Addiction Medicine (2020)
3. Benzodiazepines FOR Catatonia: Systematic Review AND Meta Analysis — Schizophrenia Research (2018)
4. Evidence Based Consensus Guidelines FOR THE Management OF Catatonia: Recommendations From THE British Association FOR Psychopharmacology — Journal of Psychopharmacology (2023)
5. Evidence Based Pharmacological Treatment OF Anxiety Disorders — Depression and Anxiety (2014)