Ativan has been related to the side effect of Obtundation. If you are taking Ativan and have experienced Obtundation this information may be of use to you.
IMPORTANT NOTE: The following information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist or other healthcare professional. It should not be construed to indicate that use of the drug is safe, appropriate, or effective for you. Consult your healthcare professional before using this drug.
Lorazepam, a benzodiazepine with antianxiety, sedative, and anticonvulsant effects, is intended for the intramuscular or
intravenous routes of administration. It has the chemical formula: 7-chloro-5(2-chlorophenyl)-1,3-dihydro-3-hydroxy-2H-1, 4-benzodiazepin-2-one.
The molecular weight is 321.16, and the C.A.S. No. is [846-49-1]. The structural formula is:
Lorazepam is a nearly white powder almost insoluble in water. Each mL of sterile injection contains either 2.0 or 4.0 mg of
lorazepam, 0.18 mL polyethylene glycol 400 in propylene glycol with 2.0% benzyl alcohol as preservative.
CLINICAL PHARMACOLOGY
Lorazepam interacts with the γ-aminobutyric acid (GABA)-benzodiazepine receptor complex, which is widespread in the brain
of humans
as well as other species. This interaction is presumed to be responsible for lorazepam’s mechanism of action. Lorazepam
exhibits relatively high and specific affinity for its recognition
site but does not displace GABA. Attachment to the specific binding site enhances the affinity of GABA for its receptor
site on the same receptor complex. The pharmacodynamic
consequences of benzodiazepine agonist actions include antianxiety effects, sedation, and reduction of seizure activity.
The intensity of action is directly related to the degree of
benzodiazepine receptor occupancy.
Effects in Pre-Operative Patients
Intravenous or intramuscular administration of the recommended dose of 2 mg to 4 mg of ATIVAN Injection to adult patients
is
followed by dose-related effects of sedation (sleepiness or drowsiness), relief of preoperative anxiety, and lack
of recall of events related to the day of surgery in the majority of
patients. The clinical sedation (sleepiness or drowsiness) thus noted is such that the majority of patients are able
to respond to simple instructions whether they give the
appearance of being awake or asleep. The lack of recall is relative rather than absolute, as determined under conditions
of careful patient questioning and testing, using props
designed to enhance recall. The majority of patients under these reinforced conditions had difficulty recalling perioperative
events or recognizing props from before surgery. The
lack of recall and recognition was optimum within 2 hours following intramuscular administration and 15 to 20 minutes
after intravenous injection.
The intended effects of the recommended adult dose of ATIVAN Injection usually last 6 to 8 hours. In rare instances, and where
patients received greater than the recommended dose, excessive sleepiness and prolonged lack of recall were noted.
As with other benzodiazepines, unsteadiness, enhanced sensitivity
to CNS-depressant effects of ethyl alcohol and other drugs were noted in isolated and rare cases for greater than
24 hours.
Physiologic Effects in Healthy Adults
Studies in healthy adult volunteers reveal that intravenous lorazepam in doses up to 3.5 mg/70 kg does not alter sensitivity
to
the respiratory stimulating effect of carbon dioxide and does not enhance the respiratory-depressant effects of doses
of meperidine up to 100 mg/70 kg (also determined by carbon
dioxide challenge) as long as patients remain sufficiently awake to undergo testing. Upper airway obstruction has
been observed in rare instances where the patient received greater
than the recommended dose and was excessively sleepy and difficult to arouse (see WARNINGS and ADVERSE REACTIONS).
Clinically employed doses of ATIVAN Injection do not greatly affect the circulatory system in the supine position or employing
a 70-degree tilt test. Doses of 8 mg to 10 mg of intravenous lorazepam (2 to 2-1/2 times the maximum recommended
dosage) will produce loss of lid reflexes within 15 minutes.
Studies in 6 healthy young adults who received lorazepam injection and no other drugs revealed that visual tracking (the
ability to keep a moving line centered) was impaired for a mean of 8 hours following administration of 4 mg of intramuscular
lorazepam and 4 hours following administration of 2 mg
intramuscularly with considerable subject variation. Similar findings were noted with pentobarbital, 150 and 75 mg.
Although this study showed that both lorazepam and pentobarbital
interfered with eye-hand coordination, the data are insufficient to predict when it would be safe to operate a motor
vehicle or engage in a hazardous occupation or sport.
Pharmacokinetics and Metabolism
Absorption
Intravenous
A 4-mg dose provides an initial concentration of approximately 70 ng/mL.
Intramuscular
Following intramuscular administration, lorazepam is completely and rapidly absorbed reaching peak concentrations
within 3 hours. A 4-mg dose provides a Cmax of approximately 48 ng/mL. Following administration of 1.5 to 5.0 mg of lorazepam IM, the amount of lorazepam delivered
to the circulation is proportional to the dose administered.
Distribution/Metabolism/Elimination
At clinically relevant concentrations, lorazepam is 91±2% bound to plasma proteins; its volume of distribution is
approximately 1.3 L/kg. Unbound lorazepam penetrates the blood/brain barrier freely by passive diffusion, a fact
confirmed by CSF sampling. Following parenteral administration,
the terminal half-life and total clearance averaged 14±5 hours and 1.1±0.4 mL/min/kg, respectively.
Lorazepam is extensively conjugated to the 3-O-phenolic glucuronide in the liver and is known to undergo enterohepatic
recirculation. Lorazepam glucuronide is an inactive metabolite and is eliminated mainly by the kidneys.
Following a single 2-mg oral dose of 14C-lorazepam to 8 healthy subjects, 88±4% of the administered dose was
recovered in urine and 7±2% was recovered in feces. The percent of administered dose recovered in urine as lorazepam
glucuronide was 74±4%. Only 0.3% of the dose was recovered as
unchanged lorazepam, and the remainder of the radioactivity represented minor metabolites.
Special Populations
Effect of Age
Pediatrics
NEONATES (BIRTH TO 1 MONTH)
Following a single 0.05 mg/kg (n=4) or 0.1 mg/kg (n=6) intravenous dose of lorazepam, mean total clearance normalized to body weight was reduced by 80% compared to normal adults, terminal half-life was prolonged 3-fold, and volume of distribution was
decreased by 40% in neonates with asphyxia neonatorum compared to normal adults. All neonates were of ≥37 weeks
of gestational age.
INFANTS (1 MONTH UP TO 2 YEARS)
There is no information on the pharmacokinetic profile of lorazepam in infants in the age range of 1 month to 2
years.
CHILDREN (2 YEARS TO 12 YEARS)
Total (bound and unbound) lorazepam had a 50% higher mean volume of distribution (normalized to body-weight) and a 30%
longer mean half-life in children with acute lymphocytic leukemia in complete remission (2 to 12 years, n=37)
compared to normal adults (n=10). Unbound lorazepam clearance normalized to body-weight was comparable in children and adults.
ADOLESCENTS (12 YEARS TO 18 YEARS)
Total (bound and unbound) lorazepam had a 50% higher mean volume of distribution (normalized to body-weight) and a mean
half-life that was two fold greater in adolescents with acute lymphocytic leukemia in complete remission (12
to 18 years, n=13) compared to normal adults (n=10). Unbound lorazepam clearance normalized to body-weight was comparable in adolescents and adults.
Elderly
Following single intravenous doses of 1.5 to 3 mg of ATIVAN Injection, mean total body clearance of lorazepam decreased
by 20% in 15 elderly subjects of 60 to 84 years of age compared to that in 15 younger subjects of 19 to 38 years
of age. Consequently, no dosage adjustment appears to be
necessary in elderly subjects based solely on their age.
Effect of Gender
Gender has no effect on the pharmacokinetics of lorazepam.
Effect of Race
Young Americans (n=15) and Japanese subjects (n=7) had very comparable mean total clearance value of 1.0 mL/min/kg.
However, elderly Japanese subjects had a 20% lower mean total clearance than elderly Americans, 0.59 mL/min/kg
vs 0.77 mL/min/kg, respectively.
Patients With Renal Insufficiency
Because the kidney is the primary route of elimination of lorazepam glucuronide, renal impairment would be expected to
compromise its clearance. This should have no direct effect on the glucuronidation (and inactivation) of lorazepam.
There is a possibility that the enterohepatic circulation of
lorazepam glucuronide leads to a reduced efficiency of the net clearance of lorazepam in this population.
Six normal subjects, six patients with renal impairment (Clcr of 22±9 mL/min), and four patients on chronic
maintenance hemodialysis were given single 1.5 to 3.0 mg intravenous doses of lorazepam. Mean volume of distribution
and terminal half-life values of lorazepam were 40% and 25%
higher, respectively, in renally impaired patients than in normal subjects. Both parameters were 75% higher in
patients undergoing hemodialysis than in normal subjects. Overall,
though, in this group of subjects the mean total clearance of lorazepam did not change. About 8% of the administered
intravenous dose was removed as intact lorazepam during the
6-hour dialysis session.
The kinetics of lorazepam glucuronide were markedly affected by renal dysfunction. The mean terminal half-life was
prolonged by 55% and 125% in renally impaired patients and patients under hemodialysis, respectively, as compared
to normal subjects. The mean metabolic clearance decreased by
75% and 90% in renally impaired patients and patients under hemodialysis, respectively, as compared with normal
subjects. About 40% of the administered lorazepam intravenous dose
was removed as glucuronide conjugate during the 6-hour dialysis session.
Hepatic Disease
Because cytochrome oxidation is not involved with the metabolism of lorazepam, liver disease would not be expected to have
an effect on metabolic clearance. This prediction is supported by the observation that following a single 2 mg
intravenous dose of lorazepam, cirrhotic male patients (n=13) and
normal male subjects (n=11) exhibited no substantive difference in their ability to clear lorazepam.
Effect of Smoking
Clinical Studies
The effectiveness of ATIVAN Injection in status epilepticus was established in two multi-center controlled trials in 177
patients. With rare exceptions, patients were between 18 and 65 years of age. More than half the patients in each
study had tonic-clonic status epilepticus; patients with simple
partial and complex partial status epilepticus comprised the rest of the population studied, along with a smaller
number of patients who had absence status.
One study (n=58) was a double-blind active-control trial comparing ATIVAN Injection and diazepam. Patients were randomized
to
receive ATIVAN 2 mg IV (with an additional 2 mg IV if needed) or diazepam 5 mg IV (with an additional 5 mg IV if
needed). The primary outcome measure was a comparison of the
proportion of responders in each treatment group, where a responder was defined as a patient whose seizures stopped
within 10 minutes after treatment and who continued seizure-free
for at least an additional 30 minutes. Twenty-four of the 30 (80%) patients were deemed responders to ATIVAN and
16/28 (57%) patients were deemed responders to diazepam (p=0.04). Of
the 24 ATIVAN responders, 23 received both 2 mg infusions.
Non-responders to ATIVAN 4 mg were given an additional 2 to 4 mg ATIVAN; non-responders to diazepam 10 mg were given an
additional 5 to 10 mg diazepam. After this additional dose administration, 28/30 (93%) of patients randomized to
ATIVAN and 24/28 (86%) of patients randomized to diazepam were deemed
responders, a difference that was not statistically significant.
Although this study provides support for the efficacy of ATIVAN as the treatment for status epilepticus, it cannot speak
reliably or meaningfully to the comparative performance of either diazepam (Valium) or lorazepam (ATIVAN Injection)
under the conditions of actual use.
A second study (n=119) was a double-blind dose-comparison trial with 3 doses of ATIVAN Injection: 1 mg, 2 mg, and 4 mg.
Patients were randomized to receive one of the three doses of ATIVAN. The primary outcome and definition of responder
were as in the first study. Twenty-five of 41 patients (61%)
responded to 1 mg ATIVAN; 21/37 patients (57%) responded to 2 mg ATIVAN; and 31/41 (76%) responded to 4 mg ATIVAN.
The p-value for a statistical test of the difference between the
ATIVAN 4 mg dose group and the ATIVAN 1-mg dose group was 0.08 (two-sided). Data from all randomized patients were
used in this test.
Although analyses failed to detect an effect of age, sex, or race on the effectiveness of ATIVAN in status epilepticus, the
numbers of patients evaluated were too few to allow a definitive conclusion about the role these factors may play.
INDICATIONS AND USAGE
Status Epilepticus
ATIVAN Injection is indicated for the treatment of status epilepticus.
Preanesthetic
ATIVAN Injection is indicated in adult patients for preanesthetic medication, producing sedation (sleepiness or drowsiness),
relief of anxiety, and a decreased ability to recall events related to the day of surgery. It is most useful in those
patients who are anxious about their surgical procedure and who
would prefer to have diminished recall of the events of the day of surgery (see PRECAUTIONS, Information for Patients).
CONTRAINDICATIONS
ATIVAN Injection is contraindicated in patients with a known sensitivity to benzodiazepines or its vehicle (polyethylene glycol,
propylene glycol, and benzyl alcohol), in patients with acute narrow-angle glaucoma, or in patients with sleep apnea
syndrome. It is also contraindicated in patients with severe
respiratory insufficiency, except in those patients requiring relief of anxiety and/or diminished recall of events
while being mechanically ventilated. The use of ATIVAN Injection
intra-arterially is contraindicated because, as with other injectable benzodiazepines, inadvertent intra-arterial injection
may produce arteriospasm resulting in gangrene which may
require amputation (see WARNINGS).
WARNINGS
Use in Status Epilepticus
Management of Status Epilepticus
Status epilepticus is a potentially life-threatening condition associated with a high risk of permanent neurological
impairment, if inadequately treated. The treatment of status, however, requires far more than the administration
of an anticonvulsant agent. It involves observation and
management of all parameters critical to maintaining vital function and the capacity to provide support of those
functions as required. Ventilatory support must be readily
available. The use of benzodiazepines, like ATIVAN Injection, is ordinarily only one step of a complex and sustained
intervention which may require additional interventions
(e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result from a correctable
acute cause such as hypoglycemia, hyponatremia, or other
metabolic or toxic derangement, such an abnormality must be immediately sought and corrected. Furthermore, patients
who are susceptible to further seizure episodes should receive
adequate maintenance antiepileptic therapy.
Any health care professional who intends to treat a patient with status epilepticus should be familiar with this package
insert and the pertinent medical literature concerning current concepts for the treatment of status epilepticus.
A comprehensive review of the considerations critical to the
informed and prudent management of status epilepticus cannot be provided in drug product labeling. The archival
medical literature contains many informative references on the
management of status epilepticus, among them the report of the working group on status epilepticus of the Epilepsy
Foundation of America “Treatment of Convulsive Status
Epilepticus” (JAMA 1993; 270:854-859). As noted in the report just cited, it may be useful to consult with a neurologist
if a patient fails to respond (e.g., fails to regain
consciousness).
For the treatment of status epilepticus, the usual recommended dose of ATIVAN Injection is 4 mg given slowly (2 mg/min) for
patients 18 years and older. If seizures cease, no additional ATIVAN Injection is required. If seizures continue
or recur after a 10- to 15- minute observation period, an
additional 4 mg intravenous dose may be slowly administered. Experience with further doses of ATIVAN is very limited. The usual precautions
in treating status epilepticus should be employed. An intravenous infusion should be started, vital signs should
be monitored, an unobstructed airway should be maintained, and
artificial ventilation equipment should be available.
Respiratory Depression
The most important risk associated with the use of ATIVAN Injection in status epilepticus is respiratory depression.
Accordingly, airway patency must be assured and respiration monitored closely. Ventilatory support should be given
as required.
Excessive Sedation
Because of its prolonged duration of action, the prescriber should be alert to the possibility, especially when multiple
doses have been given, that the sedative effects of lorazepam may add to the impairment of consciousness seen in
the post-ictal state.
Preanesthetic Use
AIRWAY OBSTRUCTION MAY OCCUR IN HEAVILY SEDATED PATIENTS. INTRAVENOUS LORAZEPAM AT ANY DOSE, WHEN GIVEN EITHER ALONE OR IN
COMBINATION WITH OTHER DRUGS ADMINISTERED DURING ANESTHESIA, MAY PRODUCE HEAVY SEDATION; THEREFORE, EQUIPMENT NECESSARY
TO MAINTAIN A PATENT AIRWAY AND TO SUPPORT
RESPIRATION/VENTILATION SHOULD BE AVAILABLE.
As is true of similar CNS-acting drugs, the decision as to when patients who have received injectable lorazepam, particularly
on an outpatient basis, may again operate machinery, drive a motor vehicle, or engage in hazardous or other activities
requiring attention and coordination must be individualized. It
is recommended that no patient engage in such activities for a period of 24 to 48 hours or until the effects of the
drug, such as drowsiness, have subsided, whichever is longer.
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.
Clinical trials have shown that patients over the age of 50 years may have a more profound and prolonged sedation with
intravenous lorazepam (see also DOSAGE AND ADMINISTRATION,
Preanesthetic).
As with all central-nervous-system-depressant drugs, care should be exercised in patients given injectable lorazepam as
premature ambulation may result in injury from falling.
There is no added beneficial effect from the addition of scopolamine to injectable lorazepam, and their combined effect may
result in an increased incidence of sedation, hallucination and irrational behavior.
General (All Uses)
PRIOR TO INTRAVENOUS USE, ATIVAN INJECTION MUST BE DILUTED WITH AN EQUAL AMOUNT OF COMPATIBLE DILUENT (see DOSAGE AND ADMINISTRATION). INTRAVENOUS INJECTION SHOULD BE MADE SLOWLY
AND WITH REPEATED ASPIRATION. CARE SHOULD BE TAKEN TO DETERMINE THAT ANY INJECTION WILL NOT BE INTRA-ARTERIAL AND
THAT PERIVASCULAR EXTRAVASATION WILL NOT TAKE PLACE. IN THE EVENT
THAT A PATIENT COMPLAINS OF PAIN DURING INTENDED INTRAVENOUS INJECTION OF ATIVAN INJECTION, THE INJECTION SHOULD
BE STOPPED IMMEDIATELY TO DETERMINE IF INTRA-ARTERIAL INJECTION OR
PERIVASCULAR EXTRAVASATION HAS TAKEN PLACE.
Since the liver is the most likely site of conjugation of lorazepam and since excretion of conjugated lorazepam (glucuronide) is
a renal function, this drug is not recommended for use in patients with hepatic and/or renal failure. ATIVAN should be used with caution in
patients with mild-to-moderate hepatic or renal disease (see DOSAGE AND
ADMINISTRATION).
Pregnancy
ATIVAN MAY CAUSE FETAL DAMAGE WHEN ADMINISTERED TO PREGNANT WOMEN. Ordinarily, ATIVAN Injection should not be used during
pregnancy except in serious or life-threatening conditions where safer drugs cannot be used or are ineffective. Status
epilepticus may represent such a serious and life-threatening
condition.
An increased risk of congenital malformations associated with the use of minor tranquilizers (chlordiazepoxide, diazepam and
meprobamate) during the first trimester of pregnancy has been suggested in several studies. In humans, blood levels
obtained from umbilical cord blood indicate placental transfer of lorazepam and lorazepam glucuronide.
Reproductive studies in animals were performed in mice, rats, and two strains of rabbits. Occasional anomalies (reduction
of
tarsals, tibia, metatarsals, malrotated limbs, gastroschisis, malformed skull, and microphthalmia) were seen in drug-treated
rabbits without relationship to dosage. Although all of
these anomalies were not present in the concurrent control group, they have been reported to occur randomly in historical
controls. At doses of 40 mg/kg orally or 4 mg/kg
intravenously and higher, there was evidence of fetal resorption and increased fetal loss in rabbits which was not
seen at lower doses.
The possibility that a woman of childbearing potential may be pregnant at the time of therapy should be considered.
There are insufficient data regarding obstetrical safety of parenteral lorazepam, including use in cesarean section. Such
use,
therefore, is not recommended.
Endoscopic Procedures
There are insufficient data to support the use of ATIVAN Injection for outpatient endoscopic procedures. Inpatient endoscopic
procedures require adequate recovery room observation time.
When ATIVAN Injection is used for peroral endoscopic procedures; adequate topical or regional anesthesia is recommended to
minimize reflex activity associated with such procedures.
PRECAUTIONS
General
The additive central-nervous-system effects of other drugs, such as phenothiazines, narcotic analgesics, barbiturates,
antidepressants, scopolamine, and monoamine-oxidase inhibitors, should be borne in mind when these other drugs are
used concomitantly with or during the period of recovery from
ATIVAN Injection (see CLINICAL PHARMACOLOGY and WARNINGS).
Extreme caution must be used when administering ATIVAN Injection to elderly patients, very ill patients, or to patients with
limited pulmonary reserve because of the possibility that hypoventilation and/or hypoxic cardiac arrest may occur.
Resuscitative equipment for ventilatory support should be readily
available (see WARNINGS and DOSAGE AND ADMINISTRATION).
When lorazepam injection is used IV as the premedicant prior to regional or local anesthesia, the possibility of excessive
sleepiness or drowsiness may interfere with patient cooperation in determining levels of anesthesia. This is most
likely to occur when greater than 0.05 mg/kg is given and when
narcotic analgesics are used concomitantly with the recommended dose (see ADVERSE REACTIONS).
As with all benzodiazepines, paradoxical reactions may occur in rare instances and in an unpredictable fashion (see ADVERSE REACTIONS). In these instances, further use of the drug in these
patients should be considered with caution.
There have been reports of possible propylene glycol toxicity (e.g., lactic acidosis, hyperosmolality, hypotension) and
possible polyethylene glycol toxicity (e.g., acute tubular necrosis) during administration of ATIVAN Injection at
higher than recommended doses. Symptoms may be more likely to
develop in patients with renal impairment.
Information for Patients
Patients should be informed of the pharmacological effects of the drug, including sedation, relief of anxiety, and lack of
recall, the duration of these effects (about 8 hours), and be apprised of the risks as well as the benefits of therapy.
Patients who receive ATIVAN Injection as a premedicant should be cautioned that driving a motor vehicle, operating machinery,
or engaging in hazardous or other activities requiring attention and coordination, should be delayed for 24 to 48
hours following the injection or until the effects of the drug, such
as drowsiness, have subsided, whichever is longer. Sedatives, tranquilizers and narcotic analgesics may produce a
more prolonged and profound effect when administered along with
injectable ATIVAN. This effect may take the form of excessive sleepiness or drowsiness and, on rare occasions, interfere
with recall and recognition of events of the day of surgery and the day after.
Patients should be advised that getting out of bed unassisted may result in falling and injury if undertaken within 8 hours
of
receiving lorazepam injection. Since tolerance for CNS depressants will be diminished in the presence of ATIVAN Injection,
these substances should either be avoided or taken in
reduced dosage. Alcoholic beverages should not be consumed for at least 24 to 48 hours after receiving lorazepam
injectable due to the additive effects on central-nervous-system
depression seen with benzodiazepines in general. Elderly patients should be told that ATIVAN Injection may make them
very sleepy for a period longer than 6 to 8 hours following
surgery.
Laboratory Tests
In clinical trials, no laboratory test abnormalities were identified with either single or multiple doses of ATIVAN Injection.
These tests included: CBC, urinalysis, SGOT, SGPT, bilirubin, alkaline phosphatase, LDH, cholesterol, uric acid,
BUN, glucose, calcium, phosphorus, and total proteins.
Drug Interactions
ATIVAN Injection, like other injectable benzodiazepines, produces additive depression of the central nervous system when
administered with other CNS depressants such as 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 behavior has been observed.
There have been rare reports of significant respiratory depression, stupor and/or hypotension with the concomitant use of
loxapine and lorazepam.
Marked sedation, excessive salivation, ataxia, and, rarely, death have been reported with the concomitant use of clozapine
and
lorazepam.
Apnea, coma, bradycardia, arrhythmia, heart arrest, and death have been reported with the concomitant use of haloperidol and
lorazepam.
The risk of using lorazepam in combination with scopolamine, loxapine, clozapine, haloperidol, or other CNS-depressant drugs
has not been systematically evaluated. Therefore, caution is advised if the concomitant administration of lorazepam
and these drugs is required.
Concurrent administration of any of the following drugs with lorazepam had no effect on the pharmacokinetics of lorazepam:
metoprolol, cimetidine, ranitidine, disulfiram, propranolol, metronidazole, and propoxyphene. No change in ATIVAN
dosage is necessary when concomitantly given with any of these drugs.
Lorazepam-Valproate Interaction
Concurrent administration of lorazepam (2 mg intravenously) with valproate (250 mg twice daily orally for 3 days) to 6
healthy male subjects resulted in decreased total clearance of lorazepam by 40% and decreased formation rate of
lorazepam glucuronide by 55%, as compared with lorazepam
administered alone. Accordingly, lorazepam plasma concentrations were about two-fold higher for at least 12 hours
post-dose administration during valproate treatment. Lorazepam
dosage should be reduced to 50% of the normal adult dose when this drug combination is prescribed in patients (see
also DOSAGE AND ADMINISTRATION).
Lorazepam-Oral Contraceptive Steroids Interaction
Coadministration of lorazepam (2 mg intravenously) with oral contraceptive steroids (norethindrone acetate, 1 mg, and
ethinyl estradiol, 50 μg, for at least 6 months) to healthy females (n=7) was associated with a 55% decrease in
half-life, a 50% increase in the volume of distribution, thereby
resulting in an almost 3.7-fold increase in total clearance of lorazepam as compared with control healthy females
(n=8). It may be necessary to increase the dose of ATIVAN in
female patients who are concomitantly taking oral contraceptives (see also DOSAGE AND ADMINISTRATION).
Lorazepam-Probenecid Interaction
Concurrent administration of lorazepam (2 mg intravenously) with probenecid (500 mg orally every 6 hours) to 9 healthy
volunteers resulted in a prolongation of lorazepam half-life by 130% and a decrease in its total clearance by 45%.
No change in volume of distribution was noted during probenecid
co-treatment. ATIVAN dosage needs to be reduced by 50% when coadministered with probenecid (see also DOSAGE AND ADMINISTRATION).
Drug and/or Laboratory Test Interactions
No laboratory test abnormalities were identified when lorazepam was given alone or concomitantly with another drug, such as
narcotic analgesics, inhalation anesthetics, scopolamine, atropine, and a variety of tranquilizing agents.
Carcinogenesis and Mutagenesis Impairment of Fertility
No evidence of carcinogenic potential emerged in rats and mice during an 18-month study with oral lorazepam. No studies
regarding mutagenesis have been performed. The results of a preimplantation study in rats, in which the oral lorazepam
dose was 20 mg/kg, showed no impairment of
fertility.
Pregnancy
Teratogenic Effects—Pregnancy Category D (See WARNINGS.)
Labor and Delivery
There are insufficient data to support the use of ATIVAN (lorazepam) Injection during labor and delivery, including cesarean
section; therefore, its use in this clinical circumstance is not recommended.
Nursing Mothers
Lorazepam has been detected in human breast milk. Therefore, lorazepam should not be administered to nursing mothers because,
like other benzodiazepines, the possibility exists that lorazepam may sedate or otherwise adversely affect the infant.
Pediatric Use
Status Epilepticus
The safety of ATIVAN in pediatric patients with status epilepticus has not been systematically evaluated. Open-label
studies described in the medical literature included 273 pediatric/adolescent patients; the age range was from
a few hours old to 18 years of age. Paradoxical excitation was
observed in 10% to 30% of the pediatric patients under 8 years of age and was characterized by tremors, agitation,
euphoria, logorrhea, and brief episodes of visual
hallucinations. Paradoxical excitation in pediatric patients also has been reported with other benzodiazepines
when used for status epilepticus, as an anesthesia, or for
pre-chemotherapy treatment.
Pediatric patients (as well as adults) with atypical petit mal status epilepticus have developed brief tonic-clonic
seizures shortly after ATIVAN was given. This “paradoxical” effect was also reported for diazepam and clonazepam.
Nevertheless, the development of seizures after treatment with
benzodiazepines is probably rare, based on the incidence in the uncontrolled treatment series reported (i.e., seizures
were not observed for 112 pediatric patients and 18 adults
or during approximately 400 doses).
Preanesthetic
There are insufficient data to support the efficacy of injectable lorazepam as a preanesthetic agent in patients less than
18 years of age.
General
Seizure activity and myoclonus have been reported to occur following administration of ATIVAN Injection, especially in very
low birth weight neonates.
Pediatric patients may exhibit a sensitivity to benzyl alcohol, polyethylene glycol and propylene glycol, components of
ATIVAN Injection (see also CONTRAINDICATIONS). The “gasping
syndrome”, characterized by central nervous system depression, metabolic acidosis, gasping respirations, and high
levels of benzyl alcohol and its metabolites found in the blood
and urine, has been associated with the administration of intravenous solutions containing the preservative benzyl
alcohol in neonates. Additional symptoms may include gradual
neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic
and renal failure, hypotension, bradycardia, and cardiovascular
collapse. Central nervous system toxicity, including seizures and intraventricular hemorrhage, as well as unresponsiveness,
tachypnea, tachycardia, and diaphoresis have been
associated with propylene glycol toxicity. Although normal therapeutic doses of ATIVAN Injection contain very small
amounts of these compounds, premature and low-birth-weight
infants as well as pediatric patients receiving high doses may be more susceptible to their effects.
Geriatric Use
Clinical studies of ATIVAN generally were not adequate to determine whether subjects aged 65 and over respond differently
than
younger subjects; however, age over 65 may be associated with a greater incidence of central nervous system depression
and more respiratory depression (see WARNINGS–Preanesthetic Use, PRECAUTIONS–General and ADVERSE REACTIONS–Preanesthetic).
Age does not appear to have a clinically significant effect on lorazepam kinetics (see CLINICAL PHARMACOLOGY).
Clinical circumstances, some of which may be more common in the elderly, such as hepatic or renal impairment, should be
considered. Greater sensitivity (e.g., sedation) of some older individuals cannot be ruled out. In general, dose
selection for an elderly patient should be cautious, usually starting
at the low end of the dosing range (see DOSAGE AND
ADMINISTRATION).
ADVERSE REACTIONS
Status Epilepticus
The most important adverse clinical event caused by the use of ATIVAN Injection is respiratory depression (see WARNINGS).
The adverse clinical events most commonly observed with the use of ATIVAN Injection in clinical trials evaluating its use
in
status epilepticus were hypotension, somnolence, and respiratory failure.
Incidence in Controlled Clinical Trials
All adverse events were recorded during the trials by the clinical investigators using terminology of their own choosing.
Similar types of events were grouped into standardized categories using modified COSTART dictionary terminology.
These categories are used in the table and listings below with
the frequencies representing the proportion of individuals exposed to ATIVAN Injection or to comparative therapy.
The prescriber should be aware that these figures cannot be used to predict the frequency of adverse events in the course
of usual medical practice where patient characteristics and other factors may differ from those prevailing during
clinical studies. Similarly, the cited frequencies cannot be
directly compared with figures obtained from other clinical investigators involving different treatment, uses,
or investigators. An inspection of these frequencies, however, does
provide the prescribing physician with one basis to estimate the relative contribution of drug and nondrug factors
to the adverse event incidences in the population
studied.
Commonly Observed Adverse Events in a Controlled Dose-Comparison Clinical Trial
Table 1 lists the treatment-emergent adverse events that occurred in the patients treated with ATIVAN Injection in a
dose-comparison trial of ATIVAN 1 mg, 2 mg, and 4 mg.
TABLE 1. NUMBER (%) OF STUDY EVENTS IN A DOSE COMPARISON CLINICAL TRIAL
Totals are not
necessarily the sum of the individual study events because a patient may report two or more different study
events in the same body system.
Commonly Observed Adverse Events in Active-Controlled Clinical Trials
In two studies, patients who completed the course of treatment for status epilepticus were permitted to be reenrolled and
to receive treatment for a second status episode, given that there was a sufficient interval between the two episodes.
Safety was determined from all treatment episodes for all
intent-to-treat patients, i.e., from all “patient-episodes.” Table 2 lists the treatment-emergent adverse events
that occurred in at least 1% of the patient-episodes in which
ATIVAN Injection or diazepam was given. The table represents the pooling of results from the two controlled trials.
TABLE 2. NUMBER (%) OF STUDY EVENTS IN ACTIVE CONTROLLED CLINICAL TRIAL
The number indicates the number of “patient-episodes.” Patient-episodes were used rather than “patients” because a total of
7 patients were reenrolled for the treatment of a second episode of status: 5 patients received ATIVAN Injection
on two occasions that were far enough apart to establish
the diagnosis of status epilepticus for each episode, and, using the same time criterion, 2 patients received
diazepam on two occasions.
Totals are not
necessarily the sum of the individual study events because a patient may report two or more different study
events in the same body system.
These trials were not designed or intended to demonstrate the comparative safety of the two treatments.
The overall adverse experience profile for ATIVAN was similar between women and men. There are insufficient data to support
a statement regarding the distribution of adverse events by race. Generally, age greater than 65 years may be associated
with a greater incidence of central-nervous-system
depression and more respiratory depression.
Other Events Observed During the Pre-Marketing Evaluation of Ativan Injection for the Treatment of Status Epilepticus
ATIVAN Injection, active comparators, and ATIVAN Injection in combination with a comparator were administered to 488
individuals during controlled and open-label clinical trials. Because of reenrollments, these 488 patients participated
in a total of 521 patient-episodes. ATIVAN Injection alone
was given in 69% of these patient-episodes (n=360). The safety information below is based on data available from
326 of these patient-episodes in which ATIVAN Injection was given
alone.
All adverse events that were seen once are listed, except those already included in previous listings (Table 1 and Table
2).
Study events were classified by body system in descending frequency by using the following definitions: frequent adverse
events were those that occurred in at least 1/100 individuals; infrequent study events were those that occurred
in 1/100 to 1/1000 individuals.
The most frequent adverse drug event reported with injectable lorazepam is central-nervous-system depression. The incidence
varied from one study to another, depending on the dosage, route of administration, use of other central-nervous-system
depressants, and the investigator’s opinion concerning the
degree and duration of desired sedation. Excessive sleepiness and drowsiness were the most common consequences
of CNS depression. This interfered with patient cooperation in
approximately 6% (25/446) of patients undergoing regional anesthesia, causing difficulty in assessing levels of
anesthesia. Patients over 50 years of age had a higher incidence
of excessive sleepiness or drowsiness when compared with those under 50 (21/106 versus 24/245) when lorazepam was
given intravenously (see DOSAGE AND ADMINISTRATION). On rare occasion (3/1580) the patient was
unable to give personal identification in the operating room on arrival, and one patient fell when attempting premature
ambulation in the postoperative period.
Symptoms such as restlessness, confusion, depression, crying, sobbing, and delirium occurred in about 1.3% (20/1580). One
patient injured himself by picking at his incision during the immediate postoperative period.
Hallucinations were present in about 1% (14/1580) of patients and were visual and self-limiting.
An occasional patient complained of dizziness, diplopia and/or blurred vision. Depressed hearing was infrequently reported
during the peak-effect period.
An occasional patient had a prolonged recovery room stay, either because of excessive sleepiness or because of some form of
inappropriate behavior. The latter was seen most commonly when scopolamine was given concomitantly as a premedicant.
Limited information derived from patients who were discharged
the day after receiving injectable lorazepam showed one patient complained of some unsteadiness of gait and a reduced
ability to perform complex mental functions. Enhanced
sensitivity to alcoholic beverages has been reported more than 24 hours after receiving injectable lorazepam, similar
to experience with other benzodiazepines.
Local Effects
Intramuscular injection of lorazepam has resulted in pain at the injection site, a sensation of burning, or observed
redness in the same area in a very variable incidence from one study to another. The overall incidence of pain
and burning in patients was about 17% (146/859) in the immediate
postinjection period and about 1.4% (12/859) at the 24-hour observation time. Reactions at the injection site (redness)
occurred in approximately 2% (17/859) in the immediate
postinjection period and were present 24 hours later in about 0.8% (7/859).
Intravenous administration of lorazepam resulted in painful responses in 13/771 patients or approximately 1.6% in the
immediate postinjection period, and 24 hours later 4/771 patients or about 0.5% still complained of pain. Redness
did not occur immediately following intravenous injection but
was noted in 19/771 patients at the 24-hour observation period. This incidence is similar to that observed with
an intravenous infusion before lorazepam is given. Intra-arterial
injection may produce arteriospasm resulting in gangrene which may require amputation (see CONTRAINDICATIONS).
Cardiovascular System
Hypertension (0.1%) and hypotension (0.1%) have occasionally been observed after patients have received injectable
lorazepam.
Respiratory System
Five patients (5/446) who underwent regional anesthesia were observed to have airway obstruction. This was believed due to
excessive sleepiness at the time of the procedure and resulted in temporary hypoventilation. In this instance,
appropriate airway management may become necessary (see alsoCLINICAL PHARMACOLOGY, WARNINGS and PRECAUTIONS).
Other Adverse Experiences
Skin rash, nausea and vomiting have occasionally been noted in patients who have received injectable lorazepam combined
with other drugs during anesthesia and surgery.
Paradoxical Reactions
As with all benzodiazepines, paradoxical reactions such as stimulation, mania, irritability, restlessness, agitation,
aggression, psychosis, hostility, rage, or hallucinations may occur in rare instances and in an unpredictable fashion.
In these instances, further use of the drug in these patients
should be considered with caution (see PRECAUTIONS,
General).
Postmarketing Reports
Voluntary reports of other adverse events temporally associated with the use of ATIVAN (lorazepam) Injection that have been
received since market introduction and that may have no causal relationship with the use of ATIVAN Injection include
the following: acute brain syndrome, aggravation of
pheochromocytoma, amnesia, apnea/respiratory arrest, arrhythmia, bradycardia, brain edema, coagulation disorder,
coma, convulsion, gastrointestinal hemorrhage, heart arrest/failure,
heart block, liver damage, lung edema, lung hemorrhage, nervousness, neuroleptic malignant syndrome, paralysis, pericardial
effusion, pneumothorax, pulmonary hypertension,
tachycardia, thrombocytopenia, urinary incontinence, ventricular arrhythmia.
Fatalities also have been reported, usually in patients on concomitant medications (e.g., respiratory depressants) and/or
with
other medical conditions (e.g., obstructive sleep apnea).
DRUG ABUSE AND DEPENDENCE
Controlled Substance Class
Lorazepam is a controlled substance in Schedule IV.
Abuse and Physical and Psychological Dependence
As with other benzodiazepines, ATIVAN Injection has a potential for abuse and may lead to dependence. Physicians should be
aware that repeated doses over a prolonged period of time may result in physical and psychological dependence and
withdrawal symptoms, following abrupt discontinuance, similar in
character to those noted with barbiturates and alcohol.
OVERDOSAGE
Symptoms
Overdosage of benzodiazepines is usually manifested by varying degrees of central-nervous-system depression, ranging from
drowsiness to coma. In mild cases symptoms include drowsiness, mental confusion and lethargy. In more serious examples,
symptoms may include ataxia, hypotonia, hypotension, hypnosis,
stages one (1) to three (3) coma, and, very rarely, death.
Treatment
Treatment of overdosage is mainly supportive until the drug is eliminated from the body. Vital signs and fluid balance should
be carefully monitored in conjunction with close observation of the patient. An adequate airway should be maintained
and assisted respiration used as needed. With normally
functioning kidneys, forced diuresis with intravenous 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. Lorazepam does not appear to be
removed in significant quantities by dialysis, although lorazepam glucuronide may be highly dialyzable. The value
of dialysis has not been adequately determined for lorazepam.
The benzodiazepine antagonist flumazenil may be used in hospitalized patients as an adjunct to, not as a substitute for, proper
management of benzodiazepine overdose. The prescriber should be aware of a risk of seizure in association with flumazenil treatment, particularly in
long-term benzodiazepine users and in cyclic antidepressant overdose. The complete flumazenil package insert including CONTRAINDICATIONS, WARNINGS and PRECAUTIONS should be consulted prior to use.
DOSAGE AND ADMINISTRATION
ATIVAN must never be used without individualization of dosage particularly when used with other medications capable of producing
central-nervous-system depression.
EQUIPMENT NECESSARY TO MAINTAIN A PATENT AIRWAY SHOULD BE IMMEDIATELY AVAILABLE PRIOR TO INTRAVENOUS ADMINISTRATION OF LORAZEPAM
(see WARNINGS).
Status Epilepticus
General Advice
Status epilepticus is a potentially life-threatening condition associated with a high risk of permanent neurological
impairment, if inadequately treated. The treatment of status, however, requires far more than the administration
of an anticonvulsant agent. It involves observation and
management of all parameters critical to maintaining vital function and the capacity to provide support of those
functions as required. Ventilatory support must be readily
available. The use of benzodiazepines, like ATIVAN Injection, is ordinarily only an initial step of a complex and
sustained intervention which may require additional
interventions, (e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result
from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an
abnormality must be immediately sought and corrected. Furthermore, patients who are susceptible to further seizure
episodes should receive adequate maintenance antiepileptic therapy.
Any health care professional who intends to treat a patient with status epilepticus should be familiar with this package
insert and the pertinent medical literature concerning current concepts for the treatment of status epilepticus.
A comprehensive review of the considerations critical to the
informed and prudent management of status epilepticus cannot be provided in drug product labeling. The archival
medical literature contains many informative references on the
management of status epilepticus, among them the report of the working group on status epilepticus of the Epilepsy
Foundation of America “Treatment of Convulsive Status
Epilepticus” (JAMA 1993; 270:854-859). As noted in the report just cited, it may be useful to consult with a neurologist
if a patient fails to respond (e.g., fails to regain
consciousness).
Intravenous Injection
For the treatment of status epilepticus, the usual recommended dose of ATIVAN Injection is 4 mg given slowly (2 mg/min) for
patients 18 years and older. If seizures cease, no additional ATIVAN Injection is required. If seizures continue
or recur after a 10- to 15-minute observation period, an
additional 4 mg intravenous dose may be slowly administered. Experience with further doses of ATIVAN is very limited. The usual precautions
in treating status epilepticus should be employed. An intravenous infusion should be started, vital signs should
be monitored, an unobstructed airway should be maintained, and
artificial ventilation equipment should be available.
Intramuscular Injection
IM ATIVAN is not preferred in the treatment of status epilepticus because therapeutic lorazepam levels may not be reached
as
quickly as with IV administration. However, when an intravenous port is not available, the IM route may prove useful
(see CLINICAL PHARMACOLOGY, Pharmacokinetics and Metabolism).
Pediatric
The safety of ATIVAN in pediatric patients has not been established.
Preanesthetic
Intramuscular Injection
For the designated indications as a premedicant, the usual recommended dose of lorazepam for intramuscular injection is
0.05 mg/kg up to a maximum of 4 mg. As with all premedicant drugs, the dose should be individualized (see also
CLINICAL PHARMACOLOGY, WARNINGS, PRECAUTIONS, and ADVERSE REACTIONS). Doses of
other central-nervous-system-depressant drugs ordinarily should be reduced (see PRECAUTIONS). For optimum effect, measured as lack of recall, intramuscular lorazepam
should be administered at least 2 hours before the anticipated operative procedure. Narcotic analgesics should be administered at their usual preoperative time.
There are insufficient data to support efficacy or make dosage recommendations for intramuscular lorazepam in patients less
than 18 years of age; therefore, such use is not recommended.
Intravenous Injection
For the primary purpose of sedation and relief of anxiety, the usual recommended initial dose of lorazepam for intravenous
injection is 2 mg total, or 0.02 mg/lb (0.044 mg/kg), whichever is smaller. This dose will suffice for sedating
most adult patients and ordinarily should not be exceeded in
patients over 50 years of age. In those patients in whom a greater likelihood of lack of recall for perioperative
events would be beneficial, larger doses as high as 0.05 mg/kg
up to a total of 4 mg may be administered (see CLINICAL
PHARMACOLOGY, WARNINGS, PRECAUTIONS, and ADVERSE REACTIONS). Doses of other injectable
central-nervous-system-depressant drugs ordinarily should be reduced (see PRECAUTIONS). For optimum effect, measured as lack of recall, intravenous lorazepam should be administered 15 to 20 minutes before the
anticipated operative procedure.
There are insufficient data to support efficacy or make dosage recommendations for intravenous lorazepam in patients less
than 18 years of age; therefore, such use is not recommended.
Dose Administration in Special Populations
Elderly Patients and Patients With Hepatic Disease
No dosage adjustments are needed in elderly patients and in patients with hepatic disease.
Patients With Renal Disease
For acute dose administration, adjustment is not needed for patients with renal disease. However, in patients with renal
disease, caution should be exercised if frequent doses are given over relatively short periods of time (see also
CLINICAL PHARMACOLOGY).
Dose Adjustment Due to Drug Interactions
The dose of ATIVAN should be reduced by 50% when coadministered with probenecid or valproate (see PRECAUTIONS, Drug Interactions).
It may be necessary to increase the dose of ATIVAN in female patients who are concomitantly taking oral
contraceptives.
Administration
When given intramuscularly, ATIVAN Injection, undiluted, should be injected deep in the muscle mass.
Injectable ATIVAN can be used with atropine sulfate, narcotic analgesics, other parenterally used analgesics, commonly used
anesthetics, and muscle relaxants.
Immediately prior to intravenous use, ATIVAN Injection must be diluted with an equal volume of compatible solution. Contents
should be mixed thoroughly by gently inverting the container repeatedly until a homogenous solution results. Do not
shake vigorously, as this will result in air entrapment. When
properly diluted, the drug may be injected directly into a vein or into the tubing of an existing intravenous infusion.
The rate of injection should not exceed 2.0 mg per minute.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration,
whenever solution and container permit. Do not use if solution is discolored or contains a precipitate.
ATIVAN Injection is compatible for dilution purposes with the following solutions: Sterile Water for Injection, USP; Sodium
Chloride Injection, USP; 5% Dextrose Injection, USP.
HOW SUPPLIED
ATIVAN (lorazepam) Injection is available in the following dosage strengths in single-dose and multiple-dose vials:
2 mg per mL,NDC 60977-112-01, 25 x 1 mL vial
NDC 60977-112-02, 10 x 10 mL vial
4 mg per mL,NDC 60977-113-01, 25 x 1 mL vial
NDC 60977-113-02, 10 x 10 mL vial
For IM or IV injection.
Store in a refrigerator.
PROTECT FROM LIGHT.
Use carton to protect contents from light.
ATIVAN is a trademark of Biovail Laboratories, Ltd.
Manufactured by
Baxter Healthcare Corporation
Deerfield, IL 60015 USA
For Product Inquiry 1 800 ANA DRUG (1-800-262-3784)
MLT-01086/1.0
ATIVAN
lorazepam
injection, solution
Product Information
Product Type
HUMAN PRESCRIPTION DRUG
NDC Product Code (Source)
60977-112
Route of Administration
INTRAVENOUS, INTRAMUSCULAR
DEA Schedule
CIV
INGREDIENTS
Name (Active Moiety)
Type
Strength
lorazepam (lorazepam)
Active
2 MILLIGRAM In 1 MILLILITER
polyethylene glycol 400
Inactive
0.18 MILLILITER In 1 MILLILITER
benzyl alcohol
Inactive
propylene glycol
Inactive
Product Characteristics
Color
Score
Shape
Size
Flavor
Imprint Code
Contains
Packaging
#
NDC
Package Description
Multilevel Packaging
1
60977-112-01
25 VIAL
In 1
PACKAGE
contains a VIAL (60977-112-81)
1
60977-112-81
1 mL
(MILLILITER)
In 1
VIAL
This package is contained within the PACKAGE (60977-112-01)
2
60977-112-02
10 VIAL
In 1
PACKAGE
contains a VIAL (60977-112-71)
2
60977-112-71
10 mL
(MILLILITER)
In 1
VIAL
This package is contained within the PACKAGE (60977-112-02)
ATIVAN
lorazepam
injection, solution
Product Information
Product Type
HUMAN PRESCRIPTION DRUG
NDC Product Code (Source)
60977-113
Route of Administration
INTRAVENOUS, INTRAMUSCULAR
DEA Schedule
CIV
INGREDIENTS
Name (Active Moiety)
Type
Strength
lorazepam (lorazepam)
Active
4 MILLIGRAM In 1 MILLILITER
polyethylene glycol 400
Inactive
0.18 MILLILITER In 1 MILLILITER
benzyl alcohol
Inactive
propylene glycol
Inactive
Product Characteristics
Color
Score
Shape
Size
Flavor
Imprint Code
Contains
Packaging
#
NDC
Package Description
Multilevel Packaging
1
60977-113-01
25 VIAL
In 1
PACKAGE
contains a VIAL (60977-113-81)
1
60977-113-81
1 mL
(MILLILITER)
In 1
VIAL
This package is contained within the PACKAGE (60977-113-01)
2
60977-113-02
10 VIAL
In 1
PACKAGE
contains a VIAL (60977-113-71)
2
60977-113-71
10 mL
(MILLILITER)
In 1
VIAL
This package is contained within the PACKAGE (60977-113-02)
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