The Hospice Clinician Blog

On November 30, the American Society of Health-Systems Pharmacists (ASHP) announced that injectable lorazepam (both generic and brand Ativan®) is in shortage. According to the ASHP website, the shortage is due to a combination of reduced production (generic manufacturer Bedford stopped making injectable lorazepam in May) and increased demand. Most back-ordered products are expected to be available sometime this month or in January 2012.

During the shortage, ASHP recommends using alternative injectable benzodiazepines, such as diazepam or midazolam.

Diazepam (Valium®)

• Can be given IV into a large peripheral vein, followed by a saline flush to decrease local venous irritation. The maximum IV rate is 5 mg per minute. Can NOT be given IM – absorption is erratic and unreliable.

• Has a more rapid onset than lorazepam and a similar duration of action.

• Normal maintenance dosing is in the range of 2-10 mg IV every 3-4 hours PRN. However, patients with severe anxiety, muscle spasm, or status epilepticus may require a loading dose (such as 10 mg IV x 1), followed by more frequent PRN dosing, to initially get symptoms under control.

• Diazepam is very lipid soluble, so it rapidly distributes into fat tissue, and stays there. So, while its duration of action is not very long, its half-life in the body can range from around 24 hours to more than 2 days. The half-life is prolonged in the elderly and in patients with liver disease. This means that it may take days to even weeks for diazepam to be completely cleared from the system when routine administration is stopped.

Midazolam (Versed®)

• Can be given IV or IM

• Has a more rapid onset but shorter duration of action than lorazepam. The half-life is only about 2 hours, so midazolam is frequently given by continuous infusion since it needs to be dosed so frequently.

• Midazolam dosing is very patient-specific and will need to be carefully titrated based on the patient’s response. A good starting point would be 0.25-0.5 mg IV, given slowly over 2 minutes, followed by slowly titrating to effect by repeating doses every 2-3 minutes if needed. If given intramuscularly, dosing requirements will be higher; if the patient is also taking narcotics, dosing requirements will be lower. Maintenance dosing is usually ~25% of the total dose required to reach the desired sedative effect.

For more information about the shortage, see the ASHP website at http://www.ashp.org/drugshortages/current/bulletin.aspx?id=747.

Let us know… has your hospice been impacted by the injectable lorazepam shortage?

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