Alcohol withdrawal syndrome (AWS) may result in nausea, vomiting, diarrhea, weakness, sweating, tremors, tachycardia, hypertension, agitation, delirium, hallucinations, seizures, and death beginning 6 hours after alcohol cessation in alcoholics.
Benzodiazepines are cross-tolerant with ethanol and are considered first-line therapy for treating AWS.
Chlordiazepoxide and diazepam are first metabolized by hepatic oxidation, then glucuronidation.
Lorazepam and oxazepam undergo only hepatic glucuronidation.
Benzodiazepine oxidation is decreased in persons with liver disease and the elderly.
Accumulation with resultant excessive sedation and respiratory depression may be significant when administering chlordiazepoxide or diazepam to patients with impaired oxidative metabolism.
Lorazepam and oxazepam metabolism is minimally affected by age and liver disease. Chlordiazepoxide and diazepam are erratically absorbed by the intramuscular route. Lorazepam is predictably absorbed by the intramuscular route. Oxazepam is not available in parenteral form. Lorazepam appears to be the safest empiric choice among the various benzodiazepines for treating AWS in the elderly and in patients with liver disease, or those who require therapy by the intramuscular route.
Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy induced nausea and vomiting, as well as for surgery to interfere with memory formation and to sedate those who are being mechanically ventilated. While it can be used for severe agitation, midazolam is usually preferred. It is also used, along with other treatments, for acute coronary syndrome due to cocaine use. It can be given by mouth or as an injection into a muscle or vein. When given by injection onset of effects is between one and thirty minutes and effects last for up to a day.
Common side effects include weakness, sleepiness, low blood pressure, and a decreased effort to breathe. When given intravenously the person should be closely monitored. Among those who are depressed there may be an increased risk of suicide. With long-term use larger doses may be required for the same effect. Physical dependence and psychological dependence may also occur.
If stopped suddenly after long-term use, benzodiazepine withdrawal syndrome may occur. Older people more often develop adverse effects. In this age group lorazepam is associated with falls and hip fractures.
Due to these concerns, lorazepam use is generally only recommended for up to two to four weeks.
Lorazepam was initially patented in 1963 and went on sale in the United States in 1977. It is on the World Health Organization’s List of Essential Medicines, the most effective and safe medicines needed in a health system. It is available as a generic medication. The wholesale cost in the developing world of a typical dose by mouth is between US$0.02 and US$0.16 as of 2014. In the United States as of 2015 a typical month supply is less than US$25. In the United States in 2011, 28 million prescriptions for lorazepam were filled making it the second most prescribed benzodiazepine after alprazolam.
Connie’s comments: Benzodiazepine should not be given to seniors who might have dementia and Alzheimer’s disease.