India · Status Epilepticus · Acute Seizure · Anxiety · Alcohol Withdrawal · Procedural Sedation · Ativan · Larpose · Lor · Loram
✓ CNS effect lasts 4–6h (diazepam: 20 min)
✓ No active metabolites that accumulate
✓ Less respiratory depression than diazepam at equivalent doses
✗ Requires refrigeration — cold chain critical
✗ Less available in district hospitals
✗ IM absorption slower than diazepam IM
| Indication | Adult dose | Paediatric dose | Route | Repeat? |
|---|---|---|---|---|
| Status epilepticus | 4 mg IV (0.1 mg/kg) | 0.1 mg/kg IV (max 4 mg) | IV over 2 min | Once after 5–10 min |
| Acute seizure (no IV) | 4 mg IM or 2–4 mg SL | 0.1 mg/kg IM (max 4 mg) | IM or sublingual | Once after 10 min |
| Procedural sedation | 1–4 mg IV slowly | 0.05 mg/kg IV (max 2 mg) | IV titrated | As needed titration |
| Acute agitation (IM) | 2 mg IM | — | IM (rapid tranquilisation) | Once after 30–60 min |
| Acute anxiety (oral) | 0.5–2 mg BD–TDS | — | Oral | Max 4 weeks (dependence) |
| Alcohol withdrawal (severe) | 2–4 mg oral/IV PRN | — | Oral or IV CIWA-guided | PRN by CIWA score |
Lorazepam (Ativan, Larpose, Lor) is a medium-acting benzodiazepine that is the preferred first-line drug for status epilepticus in international guidelines (BNF, NICE, ILAE) due to its prolonged CNS anticonvulsant effect (4–6 hours) compared to diazepam (20–30 minutes). Its major pharmacokinetic advantage is that after IV administration, it remains concentrated in the brain (CNS) for 4–6 hours without redistributing to peripheral fat stores — meaning it provides prolonged seizure suppression with a single dose, without the need for immediate second-line anticonvulsants. In India, lorazepam's use is limited by its requirement for refrigeration (2–8°C) and lower availability in district hospitals and emergency settings — making diazepam the more commonly used first-line agent in practice.
IV lorazepam 0.1 mg/kg (maximum 4 mg per dose) is the preferred first-line benzodiazepine for status epilepticus when IV access is available. Give slowly over 2 minutes with the patient monitored. May repeat once after 5–10 minutes if seizures continue. If two doses fail to terminate seizures (total ~8 mg): add second-line agent — IV levetiracetam 30–60 mg/kg, IV valproate 25–40 mg/kg, or IV phenytoin 20 mg/kg. If no IV access: IM lorazepam 0.1 mg/kg is effective (absorption 30–60 minutes). Buccal or intranasal midazolam 0.2 mg/kg is an alternative if lorazepam is unavailable.
Lorazepam injection is thermolabile and requires continuous refrigeration at 2–8°C. In Indian district hospitals, ambulances, and primary health centres — where reliable cold chain is often unavailable — lorazepam stored at room temperature for prolonged periods rapidly loses potency. This is a clinically important practical issue. When administering lorazepam, check: Is this vial from a refrigerator or cold storage? Has it been stored correctly? A degraded lorazepam vial will have reduced anticonvulsant effect. Midazolam (buccal or IM) and diazepam (rectal or IV) are more thermostable alternatives for settings without reliable cold chain.