Ativan
withdrawal. What to do for Ativan withdrawal. We provide a
step by step procedure for Ativan withdrawal. You were
probably prescribed Ativan for anxiety, however, as you now
know the Ativan withdrawal side effect is also anxiety. Many
people become confused about this anxiety; is it a return of
the old anxiety or is the anxiety part of Ativan withdrawal.
One way to tell; if the anxiety started after you reduced
the anxiety, it is probably Ativan withdrawal. If you
developed anxiety again before reducing the Ativan, it can
be due to tolerance and the current Ativan dosage simply
does not work any longer or the anxiety can just be a common
side effect of taking the Ativan.
Ativan Withdrawal
Withdrawal from Ativan needs to be methodical and gradual. Click How
to Start on the top navigation menu to read How to Get Off Psychoactive Drugs
Safely. Ativan withdrawal can be accomplished.
Ativan withdrawal is accomplished by using a pre-taper method for the first
week or two and then, after you feel very well again and stable, gradually
reducing the Ativan. The Road Back program does not suggest you switch to a
different medication, such as valium, and then taper off the Valium.
You were probably prescribed Ativan for anxiety, however, as you now know
one Ativan withdrawal side effect is also anxiety. Many people become confused about
this anxiety; is it a return of the old anxiety or is the anxiety part of
Ativan withdrawal. One way to tell; if the anxiety started after you reduced
the Ativan very slowly it is probably Ativan withdrawal. If you developed anxiety
again before reducing the Ativan, it can be due to tolerance and the current
Ativan dosage simply does not work any longer or the anxiety can just be a
common side effect of taking the Ativan.
The key to getting off Ativan is to do a few things before you even start
reducing the Ativan in order to lower the odds of Ativan withdrawal. Slow
and steady will win the race with Ativan withdrawal.
We are providing you with all chapters of How to Get Off Psychoactive Drugs
Safely on our web site, Go to the link at the top of each page, How to
Start, click it and all chapters of How to Get Off Psychoactive Drugs
Safely
is located on that page.
If you would like to receive this book for free as an eBook (pdf file)
click
here.
If you just want to get relief from the Ativan withdrawal side effects;
click the link below for supplements, select your country and get the Neuro
Day and Neuro Night. Just use the instructions on the bottle for time and
amount to take.
The supplements are available in most
countries. Click here
Ativan info from National Institutes of Health
Click here
To search the FDA web site for Ativan
click here
Pharmacology
Anxiolytic - Sedative
Lorazepam is a
benzodiazepine with CNS depressant, anxiolytic and sedative
properties. Peak serum concentrations of free lorazepam
after oral administration are reached in 1 to 6 hours.
Peak concentrations are reached in 60 to 90 minutes after
i.m. administration and in 60 minutes after sublingual
administration. Lorazepam is 85% bound to plasma
proteins. Lorazepam is rapidly conjugated to an inactive
glucuronide. Very small amounts of other metabolites have
also been isolated in man. The serum half-life of
lorazepam is approximately 12 to 15 hours while the
half-life of the conjugate is 16 to 20 hours.
Ninety-five percent of the drug was excreted within 120
hours, 88% in the urine and 6.6% in the stool.
Anterograde amnesia,
decreased or lack of recall of events during period of drug
action, has been reported after administration of lorazepam
and appears to be dose-related.
Indications
The short-term relief of
manifestations of excessive anxiety in patients with anxiety
neurosis. Adjunct for the relief of excessive anxiety that
might be present prior to surgical procedures.
Anxiety and tension
associated with the stresses of everyday life usually do not
require treatment with anxiolytic drugs.
Injectable lorazepam is
useful as an initial anticonvulsant medication for the
control of status epilepticus.
Contraindications
Myasthenia gravis, acute
narrow angle glaucoma, known hypersensitivity to
benzodiazepines. Lorazepam injectable is also
contraindicated in patients with known hypersensitivity to
polyethylene glycol, propylene glycol or benzyl alcohol.
Lorazepam should not be
injected intra-arterially and care should be taken to
prevent its extravasation into tissue adjacent to an artery
because of the danger of producing arteriospasm resulting in
gangrene which may require amputation.
Warnings
Lorazepam is not
recommended for use in depressive neurosis or in psychotic
reactions. Because of the lack of sufficient clinical
experience, lorazepam is not recommended for use in patients
less than 18 years of age. Since lorazepam has a CNS
depressant effect, patients should be advised against the
simultaneous use of other CNS depressant drugs.
Patients should also be cautioned not to take alcohol during
the administration of lorazepam because of the potentiation
of effects that may occur.
Occupational
Hazards:
Excessive sedation has been
observed with lorazepam at standard therapeutic doses.
Therefore, patients should be warned against engaging in
hazardous activities requiring mental alertness and motor
coordination, such as operating dangerous machinery or
driving motor vehicles.
Prior to i.v. use,
lorazepam injection should be diluted with an equal amount
of compatible diluent (see Dosage). I.V. injection should be
made slowly and with repeated aspiration. Care should be
taken to determine that any injection will not be
intraarterial and that perivascular extravasation will not
take place. Partial airway obstruction may occur in heavily
sedated patients. I.V. lorazepam, when given alone in
greater than the recommended dose, or at the recommended
dose and accompanied by other drugs used during the
administration of anesthesia, may produce heavy sedation;
therefore, equipment necessary to maintain a patent airway
and to support respiration/ventilation should be available.
As with any premedicant,
extreme care must be used in administering lorazepam
injection to elderly or very ill patients and to those with
limited pulmonary reserve, because of the possibility that
apnea and/or cardiac arrest may occur. Because of the lack
of sufficient clinical experience lorazepam injection is not
recommended for use in patients less than 18 years of age.
Clinical trials have shown
that patients over the age of 50 years may have a more
profound and prolonged sedation with i.v. lorazepam.
Ordinarily an initial dose of 2 mg may be adequate, unless a
greater degree of lack of recall is desired.
There is no evidence to
support the use of lorazepam injection in coma, shock or
acute alcohol intoxication at this time. When lorazepam
injection 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.
As is true of other similar
CNS acting drugs, patients receiving injectable lorazepam
should not operate machinery or engage in hazardous
occupations or drive a motor vehicle for a period of 24 to
48 hours. Impairment of performance may persist for greater
intervals because of extremes of age, concomitant use of
other drugs, stress of surgery or the general condition of
the patient.
The addition of scopolamine
to injectable lorazepam is not recommended, since their
combined effect may result in increased incidence of
sedation, hallucination and irrational behaviour.
Care should be exercised
when administering lorazepam to patients with status
epilepticus, especially when the patient has received other
CNS depressants or is severely ill. The possibility that
respiratory arrest may occur or that the patient may have
partial airway obstruction should be considered. Proper
resuscitation equipment should be available.
Pregnancy:
The safety of the use of
lorazepam in pregnancy has not been established. Therefore,
it is not recommended for use during pregnancy or lactation.
Several studies have suggested an increased risk of
congenital malformations associated with the use of the
benzodiazepines, chlordiazepoxide and diazepam, and
meprobamate, during the first trimester of pregnancy. Since
lorazepam is also a benzodiazepine derivative, its
administration is rarely justified in women of childbearing
potential. If the drug is prescribed to a woman of
childbearing potential, she should be warned to contact her
physician regarding discontinuation of the drug if she
intends to become or suspects that she is pregnant.
In women, blood levels
obtained from umbilical cord blood indicate placental
transfer of lorazepam and lorazepam glucuronide. Lorazepam
injection should not be used during pregnancy. There are
insufficient data regarding obstetrical safety of parenteral
lorazepam, including use in cesarean section. Such use,
therefore, is not recommended.
Precautions
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
in these patients with very low initial doses, and
increments should be made gradually, depending on the
patient's response, in order to avoid oversedation or
neurological impairment. Extreme care must be used in
administering lorazepam injection to elderly patients, very
ill patients, and to patients with limited pulmonary
reserve, because of the possibility that underventilation
and/or hypoxic cardiac arrest may occur. Resuscitative
equipment for ventilatory support should be readily
available.
Lorazepam should not be
administered to individuals prone to drug abuse.
Observe caution in patients
who are considered to have potential for psychological
dependence. Lorazepam should be withdrawn gradually if
it has been used in high dosage.
As with other
benzodiazepines, lorazepam injection has a low potential for
abuse and may lead to limited dependence. Although there are
no clinical data available for injectable lorazepam in this
respect, physicians should be aware that repeated doses over
a prolonged period of time may result in limited physical
and psychological dependence.
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 nonpathological anxiety. These drugs are also
not effective in patients with characterological and
personality disorders or those with obsessive-compulsive
neurosis.
When using lorazepam, it
should be recognized that suicidal tendencies may be present
and that protective measures may be required.
Since the liver is the most
likely site of conjugation of lorazepam and since excretion
of conjugated lorazepam is a renal function, the usual
precautions should be taken if lorazepam is used in patients
who may have some impairment of renal or hepatic function.
In such cases, the dose should be very carefully titrated.
In patients for whom
prolonged lorazepam therapy is indicated, periodic blood
counts and liver function tests should be carried out.
When injectable 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.
While lorazepam has been
shown to control status epilepticus promptly, it is not
recommended for maintenance treatment of epilepsy. After
seizures are controlled, agents useful in the prevention of
further seizures should be administered. In the treatment of
status epilepticus due to acute reversible metabolic
derangement (e.g., hypoglycemia, hypocalcemia, hyponatremia)
immediate efforts should be made to correct the specific
defect.
Drug
Interactions:
If lorazepam is to be
combined with other drugs acting on the CNS, careful
consideration should be given to the pharmacology of the
agents to be employed because of the possible potentiation
of drug effects. The benzodiazepines, including lorazepam,
produce CNS depressant effects when administered with such
medications as barbiturates or alcohol.
Lorazepam injection, like
other injectable benzodiazepines, also produces depression
of the CNS when administered with ethyl alcohol,
phenothiazines, barbiturates, MAO inhibitors and other
antidepressants. When scopolamine is used concomitantly with
injectable lorazepam, an increased incidence of sedation,
hallucinations and irrational behaviour has been observed.
When lorazepam injection is
used i.v. as the premedicant prior to regional or local
anesthesia, the possibility of excessive sleepiness or
drowsiness may interfere with patient cooperation to
determine levels of anesthesia. This is most likely to occur
when a dose greater than 0.05 mg/kg is given and when
narcotic analgesics are used concomitantly with the
recommended dose.
Adverse Effects
Drowsiness is the most
frequently reported adverse effect. Other reported adverse
effects are dizziness, weakness, fatigue and lethargy,
disorientation, ataxia, anterograde amnesia, nausea, change
in appetite, change in weight, depression, blurred vision
and diplopia, psychomotor agitation, sleep disturbance,
vomiting, sexual disturbance, headache, skin rashes,
gastrointestinal, ear, nose and throat, musculoskeletal and
respiratory disturbances.
Release of hostility and
other paradoxical effects, such as irritability and
excitability have occurred with benzodiazepines. In
addition, hypotension, mental confusion, slurred speech,
oversedation and abnormal liver and kidney function tests
and hematocrit values have been reported with these drugs.
The most frequent adverse
effects seen with injectable lorazepam are an extension of
the CNS depressant effects of the drug. Excessive sleepiness
and drowsiness are the main side effects: the incidences
reported depended on the dosage, route of administration,
concomitant use of other CNS depressants and the
investigators' expectations concerning the degree and
duration of sedation.
When injectable lorazepam
was given i.v., patients over 50 years of age had a higher
incidence of excessive sedation than patients under 50 years
of age. Restlessness, confusion, depression, crying,
sobbing, delerium, hallucinations, dizziness, diplopia have
been reported. Hypertension and hypotension have
occasionally been observed after injectable lorazepam.
Respiratory depression and
partial airway obstruction have been observed after
injectable lorazepam. Skin rash, nausea and vomiting have
been noted occasionally in patients who have received
injectable lorazepam combined with other drugs during
anesthesia and surgery.
Pain at the injection site,
a sensation of burning, and redness in the same area have
been reported after i.m. administration of injectable
lorazepam. Pain in the immediate postinjection period and
redness at the 24 hour observation period also have been
reported after i.v. administration of injectable lorazepam.
Overdose
Symptoms:
With benzodiazepines,
including lorazepam, symptoms of mild overdosage include
drowsiness, mental confusion and lethargy. In more serious
overdosage, symptoms may include ataxia, hypotonia,
hypotension, hypnosis, stages I to III coma and, very
rarely, death.
Treatment:
In the case of an oral
overdose, if vomiting has not occurred spontaneously and the
patient is fully awake, it may be induced with 20 to 30 mL
of ipecac syrup USP. Institute gastric lavage as soon as
possible, and introduce 50 to 100 g of activated charcoal to
the stomach and allow it to remain there. Institute general
supportive therapy as indicated. Vital signs and fluid
balance should be carefully monitored. An adequate airway
should be maintained and assisted respiration used as
needed. With normally functioning kidneys, forced diuresis
with i.v. fluids and electrolytes may accelerate elimination
of benzodiazepines from the body. In addition, osmotic
diuretics such as mannitol may be effective as adjunctive
measures. In more critical situations, renal dialysis and
exchange blood transfusions may be indicated. Published
reports indicate that i.v. infusion of 0.5 to 4 mg of
physostigmine at the rate of 1 mg/minute may reverse
symptoms and signs suggestive of central anticholinergic
overdose (confusion, memory disturbance, visual
disturbances, hallucinations, delirium); however, hazards
associated with the use of physostigmine (i.e., induction of
seizures) should be weighed against its possible clinical
benefit.
Dosage
Dosage must be
individualized and carefully titrated in order to avoid
excessive sedation or mental and motor impairment. As with
other anxiolytic sedatives, short courses of treatment
should usually be the rule for the symptomatic relief of
disabling anxiety in psychoneurotic patients and the initial
course of treatment should not last longer than 1 week
without reassessment of the need for a limited extension.
Initially, not more than 1 week's supply of the drug should
be provided and automatic prescription renewals should not
be allowed. Subsequent prescriptions, when required, should
be limited to short courses of therapy.
Generalized
anxiety disorder:
The recommended initial
adult daily oral dosage is 2 mg in divided doses of 0.5 mg,
0.5 mg and 1 mg, or of 1 mg and 1 mg. The daily dosage
should be carefully increased or decreased by 0.5 mg
depending upon tolerance and response. The usual daily
dosage is 2 to 3 mg. However, the optimal dosage may range
from 1 to 4 mg daily in individual patients. Usually, a
daily dosage of 6 mg should not be exceeded.
The initial daily dose in
elderly and debilitated patients should not exceed 0.5 mg
and should be very carefully and gradually adjusted,
depending upon tolerance and response.
Excessive
anxiety prior to surgical procedures:
Adults:
Usually 50 mcg/kg to a
maximum of 4 mg given sublingually (1 to 2 hours before
surgery) or i.m. (2 to 3 hours before surgery). As with all
premedicant drugs, the dose should be individualized. Doses
of other CNS depressant drugs should ordinarily be reduced.
When a rapid onset of
action is required, lorazepam may be given i.v., 15 to 20
minutes before surgery. The usual i.v. dose is 44 mcg/kg or
2.0 mg total, whichever is smaller.
I.V. doses in excess of 2
mg should be restricted to patients of unusual size. A dose
of 2 mg should not ordinarily be exceeded in patients over
50 years of age. Doses of other CNS depressants should
ordinarily be reduced.
Equipment necessary to
maintain a patent airway should be immediately available
prior to i.v. administration of lorazepam.
Status
Epilepticus:
Adults:
The usual recommended initial dose of lorazepam is 0.05
mg/kg up to a maximum of 4 mg given by slow i.v. injection.
If seizures are terminated, no additional lorazepam is
required. If seizures continue or recur after a 10 to 15
minute observation period, an additional i.v. dose of 0.05
mg/kg may be administered. If the second dose does not
result in seizure control after another 10 to 15 minute
observation period, other measures to control status
epilepticus should be employed. A maximum of 8 mg only, of
lorazepam, should be administered during a 12 hour period.
Administration:
The sublingual tablet, when
placed under the tongue, will dissolve in approximately 20
seconds. The patients should not swallow for at least 2
minutes to allow sufficient time for absorption.
When given i.m., lorazepam
injection, undiluted, should be injected deep into a muscle
mass.
Lorazepam injectable can be
used with atropine sulfate, narcotic analgesics, other
parenterally used analgesics, commonly used anesthetics and
muscle relaxants. The use of scopolamine with lorazepam
injection is not recommended since this combination has been
associated with a higher incidence of adverse reactions.
Immediately prior to i.v.
use, lorazepam injection must be diluted with an equal
volume of compatible solution. When properly diluted the
drug may be injected directly into the vein or into the
tubing of an existing i.v. infusion. The rate of injection
should not exceed 2 mg/minute. Parenteral drug products
should be inspected visually for particulate matter and
discoloration prior to administration. Do not use if
solution is discolored or contains a precipitate.
Lorazepam injection is
compatible for dilution purposes with the following
solutions: Sterile Water for Injection, USP, Sodium Chloride
Injection, USP, 5% Dextrose Injection, USP, Bacteriostatic
Sodium Chloride Injection, USP with benzyl alcohol,
Bacteriostatic Water for Injection, USP with parabens,
Bacteriostatic Water for Injection, USP with benzyl alcohol.
Directions for dilution for
i.v. use:
Aspirate the desired amount of lorazepam injection into the
syringe, then slowly aspirate the desired volume of diluent.
Pull back slightly on the plunger to provide additional
mixing space. Immediately mix contents thoroughly by gently
inverting the syringe repeatedly until a homogenous solution
results. Do not shake vigorously since this will result in
air entrapment.
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