Source: Υπουργείο Υγείας (CY) Revision Year: 2017 Publisher: MEDOCHEMIE LTD, 1-10 Constantinoupoleos street, 3011 Limassol, Cyprus
Use of benzodiazepines, including lorazepam, may lead to potentially fatal respiratory depression.
Severe anaphylactic/anaphylactoid reactions have been reported with the use of benzodiazepines. Cases of angioedema involving the tongue, glottis or larynx have been reported in patients after taking the first or subsequent doses of benzodiazepines. Some patients taking benzodiazepines have had additional symptoms such as dyspnoea, throat closing, or nausea and vomiting. Some patients have required medical therapy in the emergency department. If angioedema involves the tongue, glottis or larynx, airway obstruction may occur and be fatal. Patients who develop angioedema after treatment with a benzodiazepine should not be rechallenged with the drug.
Lorazepam should be used with caution in patients with compromised respiratory function (e.g., COPD, sleep apnoea syndrome).
Patients should be advised that since their tolerance for alcohol and other CNS depressants will be diminished in the presence of lorazepam, these substances should either be avoided or taken in reduced dosage.
Anxiety or insomnia may be a symptom of several other disorders. The possibility should be considered that the complaint may be related to an underlying physical or psychiatric disorder for which there is more specific treatment.
Abuse of benzodiazepines has been reported, especially in patients with a history of drug and/or alcohol abuse.
Some loss of efficacy to the hypnotic effects of short-acting benzodiazepines may develop after repeated use for a few weeks. There is evidence that tolerance develops to the sedative effects of benzodiazepines. Lorazepam may have abuse potential, especially in patients with a history of drug and/or alcohol abuse.
The use of benzodiazepines may lead to physical and psychological dependence. The risk of dependence on lorazepam is low when used at the recommended dose and duration, but increases with higher doses and longer term use. The risk of dependence is further increased in patients with a history of alcoholism or drug abuse, or in patients with significant personality disorders. Therefore, use in individuals with a history of alcoholism or drug abuse should be avoided.
Dependence may lead to withdrawal symptoms, especially if treatment is discontinued abruptly. Therefore, the drug should always be discontinued gradually.
Withdrawal symptoms (e.g. rebound insomnia) can appear following cessation of recommended doses after as little as one week of therapy. Abrupt termination of treatment may be accompanied by withdrawal symptoms.
Symptoms reported following discontinuation of benzodiazepines include headaches, muscle pain, anxiety, tension, depression, insomnia, restlessness, dizziness, nausea, diarrhoea, loss of appetite, confusion, hallucinations/delirium, perceptual changes, irritability, dysphoria, convulsions/seizures, tremor, abdominal cramps, myalgia, agitation, palpitations, tachycardia, panic attacks, vertigo, hyperreflexia, short-term memory loss, hyperthermia, sweating, and the occurrence of “rebound” phenomena whereby the symptoms that led to treatment with benzodiazepines recur in an enhanced form.
These symptoms may be difficult to distinguish from the original symptoms for which the drug was prescribed.
In severe cases the following symptoms may occur: derealisation, depersonalization, hyperacusis, tinnitus, numbness and tingling of the extremities, hypersensitivity to light, noise, and physical contact/perceptual changes, involuntary movements, vomiting, hallucinations; convulsions.
Convulsions/seizures may be more common in patients with pre-existing seizure disorders or who are taking other drugs that lower the convulsive threshold such as antidepressants.
Treatment should be as short as possible. Generally, the duration of treatment varies from a few days to 4 weeks including the tapering off process.
It may be useful to inform the patient that treatment will be of limited duration and that it will be discontinued gradually.
The patient should also be made aware of the possibility of “rebound” phenomena to minimise anxiety should they occur.
There are indications that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high.
When benzodiazepines with a long duration of action are being used it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.
Transient anterograde amnesia or memory impairment has been reported in association with the use of benzodiazepines.
This effect may be advantageous when lorazepam is used as a premedicant. However, if lorazepam is used for insomnia due to anxiety, patients should ensure that they will be able to have a period of uninterrupted sleep which is sufficient to allow dissipation of drug effect (e.g., 7-8 hours).
Paradoxical reactions have been occasionally reported during benzodiazepine use (see section 4.8). Such reactions may be more likely to occur in children and the elderly. Should these occur, use of the drug should be discontinued.
Lorazepam is not intended for the primary treatment of psychotic illness or depressive disorders, and should not be used alone to treat depressed patients. The use of benzodiazepines may have a disinhibiting effect and may release suicidal tendencies in depressed patients. Therefore, large quantities of lorazepam should not be prescribed to these patients. The use of benzodiazepines in these patients should not be used without adequate antidepressant therapy.
Pre-existing depression may emerge during benzodiazepine use.
Caution should be used in the treatment of patients with acute narrow-angle glaucoma.
Patients with impaired renal function or mild to moderate hepatic insufficiency should be monitored frequently and have their dosage adjusted carefully according to patient response. Lower doses may be sufficient in these patients.
The same precautions apply to elderly or debilitated patients and patients with chronic respiratory insufficiency.
As with all CNS-depressants, the use of benzodiazepines may precipitate encephalopathy in patients with severe hepatic insufficiency. Therefore, use in these patients is contraindicated.
Some patients taking benzodiazepines have developed a blood dyscrasia, and some have had elevations in liver enzymes. Periodic haematologic and liver-function assessments are recommended where repeated courses of treatment are considered clinically necessary.
Although hypotension has occurred only rarely, benzodiazepines should be administered with caution to patients in whom a drop in blood pressure might lead to cardiovascular or cerebrovascular complications. This is particularly important in elderly patients.
Elderly patients should be warned of the risk of falls due to the myorelaxant effect of lorazepam.
Lorans contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Concomitant intake with alcohol is not recommended.
The sedative effects may be enhanced when the product is used in combination with alcohol. This affects the ability to drive or use machines.
The benzodiazepines, including lorazepam produce additive CNS depressant effects when coadministered with other medications which themselves produce CNS depression e.g., barbiturates, antipsychotics, sedatives/hypnotics, anxiolytics, antidepressants, narcotic analgesics, sedative antihistamines, anticonvulsants, and anaesthetics.
An enhancement of the euphoria induced by narcotic analgesics may occur with benzodiazepine use, leading to an increase in psychic dependence.
Compounds which inhibit certain hepatic enzymes (particularly cytochrome P450) may enhance the activity of benzodiazepines. To a lesser degree this also applies to benzodiazepines which are metabolised only by conjugation.
There have been reports of excessive stupor, significant reduction in respiratory rate and, in one patient, hypotension when Lorazepam and loxapine have been given concomitantly.
There have been reports of marked sedation, excessive salivation, and ataxia when Lorazepam and clozapine have been given concomitantly.
Concurrent administration of lorazepam with sodium valproate may result in increased plasma concentrations and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50% when coadministered with sodium valproate.
Concurrent administration of lorazepam with probenecid may result in a more rapid onset or prolonged effect of lorazepam due to increased half-life and decreased total clearance. Lorazepam dosage needs to be reduced by approximately 50% when coadministered with probenecid.
Administration of theophylline or aminophylline may reduce the sedative effects of benzodiazepines, including lorazepam.
Benzodiazepines should not be used during pregnancy, especially during the first and last trimesters. Benzodiazepines may cause foetal damage when administered to pregnant women. In particular, an increased risk of congenital malformations associated with the use of benzodiazepines during the first trimester of pregnancy has been suggested in several studies. In humans, umbilical cord blood samples indicate placental transfer of benzodiazepines and their glucuronide metabolites.
If the drug is prescribed to a woman of childbearing potential, she should be warned to contact her physician about stopping the drug if she intends to become, or suspects that she is, pregnant.
If, for compelling medical reasons, the product is administered during the late phase of pregnancy, or during labour at high doses, effects on the neonate can be expected due to the pharmacological action of the compound.
Infants of mothers who ingested benzodiazepines for several weeks or more preceding delivery have been reported to have withdrawal symptoms during the postnatal period.
Symptoms such as, hypoactivity, hypotonia, hypothermia, respiratory depression, apnoea, feeding problems, and impaired metabolic response to cold stress have been reported in neonates born of mothers who have received benzodiazepines during the late phase of pregnancy or at delivery.
There is evidence that lorazepam is excreted, albeit in pharmacologically insignificant amounts, in human breast milk.
Therefore, lorazepam should not be given to breastfeeding mothers unless the expected benefit to the mother outweighs the potential risk to the infant. Sedation and inability to suckle have occurred in neonates of lactating mothers taking benzodiazepines. Infants of lactating mothers should be observed for pharmacological effects (including sedation and irritability).
Sedation, amnesia, impaired concentration and impaired muscular function may adversely affect the ability to drive or to use machines. If insufficient sleep occurs, the likelihood of impaired alertness may be increased (see section 4.5). Patients should be warned not to operate dangerous machinery or motor vehicles if any of these effects occur.
Adverse reactions, when they occur, are usually observed at the beginning of therapy and generally decrease in severity or disappear with continued use or upon decreasing the dose. The frequency of reporting the undesirable effects below is: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).
Common: Muscle weakness, asthenia.
Not known: Hypersensitivity reactions, anaphylactic/anaphylactoid reactions, angioedema, SIADH, hyponatraemia, hypothermia.
Not known: Hypotension, lowering in blood pressure.
Uncommon: Nausea.
Not known: Constipation, increase in bilirubin, jaundice, increase in liver transaminases, increase in alkaline phosphatase.
Not known: Thrombocytopenia, agranulocytosis, pancytopenia.
Very common: Sedation, fatigue, drowsiness.
Common: Ataxia, confusion, depression, unmasking of depression, dizziness.
Not known: Benzodiazepine effects on the CNS are dose dependent, with more severe CNS depression occurring with high doses.
Extrapyramidal symptoms, tremor, vertigo, visual disturbances (including diplopia and blurred vision), dysarthria/slurred speech, headache, convulsions/seizures; amnesia, disinhibition, euphoria, coma, suicidal ideation/attempt, impaired attention/concentration, balance disorder
Paradoxical reactions including anxiety, agitation, excitation, hostility, aggression, rage, sleep disturbances/insomnia, sexual arousal, hallucinations.
Uncommon: Change in libido, impotence, decreased orgasm.
Not known: Respiratory depression, apnoea, worsening of sleep apnoea (the extent of respiratory depression with benzodiazepines is dose dependent, with more severe depression occurring with high doses).
Worsening of obstructive pulmonary disease.
Not known: Allergic skin reactions, alopecia.
Pre-existing depression may emerge during benzodiazepine use.
Transient anterograde amnesia or memory impairment may occur using therapeutic doses, the risk increasing at higher doses (see section 4.4).
Paradoxical reactions such as restlessness, agitation, irritability, aggressiveness, delusion, rage, nightmares, hallucinations, psychoses, and inappropriate behaviour have been occasionally reported during benzodiazepine use.
Such reactions may be more likely to occur in children and the elderly (see section 4.4).
Use (even at therapeutic doses) may lead to physical or psychological dependence and discontinuation of treatment may result in withdrawal reactions or rebound phenomena (see section 4.4).
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions to Pharmaceutical Services, Ministry of Health, CY-1475, www.moh.gov.cy/phs, Fax: +357 22608649.
No known incompatibilities.
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