Pharmacology Critical Thinking Assignment: Lorazepam

The individual I interviewed is an 18-year-old male who is currently taking lorazepam help control anxiety and panic attacks. He is a healthy teenager who values exercise and eating healthy but struggles with depression, anxiety and panic attacks. He has suffered from depression and anxiety for roughly five years and had panic attacks for one and a half years before starting medication. He states his panic attacks are usually manageable but have caused him to have pseudo seizures (psychogenic nonepileptic seizures) in the past. This is when a person has a seizure that is a result of psychological condition, such as generalized anxiety attacks, panic attacks, or substance abuse. He stated that when he had these pseudo seizures, he felt his panic attack was so severe he thought he was going to die. The individual does not take any other medications but was previously prescribed an SSRI called citalopram. He was not able to continue taking this medication as it was causing more anxiety.

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 Lorazepam, an antianxiety medication, was prescribed to this individual because he was having panic attacks 3 or more times per week and severe anxiety. It was affecting his day to day life to a point where he was unable to attend work and spend a full day in school. This medication was prescribed PRN, he takes lorazepam when the feeling of a panic attack arises. He started this medication in November of 2018, he has been taking it for roughly 3 months and feels it has helped him greatly. He has not had to leave work or school due to a panic attack since he started taking lorazepam, he states that he is only having panic attacks 2-3 times per week and he feels they are more controllable. He has not had a pseudo seizure since starting lorazepam. While there are many uses for lorazepam it is most often used to treat generalize anxiety disorder or insomnia. It is also used as an anxiolytic, sedative, status epilepticus and pre-anaesthetic. This individual takes lorazepam in a 1 mg dose, he takes it sublingually, which means he lets it dissolve under his tongue. He does not take the drug with water or food.

 Lorazepam is a form of benzodiazepine that “acts by potentiating the effects of GABAᴀ, an inhibitory neurotransmitter, in the thalamic, hypothalamic, and limbic levels of the CNS” (Adams, Urban, El-Hussein, Osuji, King, pg. 170). The brand name of this drug is Ativan. There are common side effects such as dizziness, drowsiness, disorientation, anterograde amnesia, sedation, ataxia, and blurred vision. The less common side effects include hepatotoxicity, alopecia, anaphylaxis, tachycardia, paradoxical CNS stimulation, and cardiac arrest when used with rapid IVs. When speaking to the individual he explained some of the side effects he has experienced. He stated he feels extremely tired after taking lorazepam and often falls asleep shortly after taking it. He has also felt disoriented and claims he often feels like a “zombie” after taking one dose of lorazepam. He feels extreme thirst and his legs feel heavy but also restless. His side effects seem to be under the more common side effects of taking a benzodiazepine. When asked if he has ever felt like his heart is racing or if he has temporary cessation of breathing the individual stated he has not. Lorazepam is addictive and people using this drug can develop a tolerance, because of this it is often suggested that clients try to treat or reduce anxiety in other ways before starting lorazepam. It is important for the health care provider to inform the patient not to take more than the prescribed amount as dependency can develop. When taking lorazepam, it is important to avoid consumption of alcohol. When mixed with other CNS depressants such as alcohol it can cause respiratory depression or death. Since the individual I interviewed is a teenager it is important to stress to him the importance of not mixing lorazepam and alcohol or consuming more than 500 mg of caffeine. Having large amounts of caffeine can “significantly alter anxiolytic effects of lorazepam” (Adams, Urban, El-Hussein, Osuji, King, pg. 170). Patients are advised not to discontinue lorazepam abruptly after long-term use.

 The patient’s respirations must be taken every 5 to 15 minutes if administered through an IV (Adams, et al., 2010). It is also extremely important to monitor physical dependency and withdrawal symptoms including; headache, nausea, vomiting, seizures, tremors, muscle pain and weakness after being used for long periods of time (Skidmore-Roth, 2019). As a nurse, I need to also assess if there is a decrease in anxiety, change in sleeping patterns, drowsiness, dizziness, or suicidal tendencies. For clients receiving high doses renal, hepatic, and blood status needs to be monitored. I will need to complete a health history including allergies and use of other CNS stimulants or depressants. I will establish baseline vitals and level of consciousness as well as assess the likelihood of abuse. Abuse may occur if a patient has abuse other drugs in the past, is a chronic drinker or has been through a traumatizing experience. An important step is to educate my clients on drug actions and the side effects.

 Health teachings should include avoiding OTC drugs such as cough syrups and cold medications unless approved by prescriber. The prescribe must also approve the use of alcohol and psychotropic medications, if not approved use of these things should be avoided. It is extremely important to report suicidal ideation and planned or suspected pregnancy as lorazepam is in the pregnancy category D. This medication should not be discontinued abruptly after long-term use, it should not be used for every day stresses or for over 4 months unless directed by prescriber. Lorazepam can cause dizziness and drowsiness so patients taking this medication should avoid driving, other activities that require alertness, and stand up slowly because fainting may occur. It is also possible that drowsiness may worsen at beginning of treatment (Skidmore-Roth, 2019). When being interviewed the individual was asked what health teachings or information he received before starting lorazepam. He stated he knows not to mix alcohol and lorazepam because it can have serious adverse effects and even cause death. He stated he had no other health teachings or assessments done when being prescribed this medication. He knows he needs to be aware of serious adverse effects and report them immediately. Despite the lack of health teachings, I believe the individual is taking this medication safely. He is taking the medication as directed by his doctor, he takes 1 tab sublingually when he feels a panic attack starting. He does not take this medication if it is not needed, he feels the medication is effective with helping control his panic attacks and reduce his anxiety. He is noticing a reduction in the amount of panic attacks he has and the severity of these panic attacks. The individual feels he is in control of his life for the first time in roughly one and a half years. After speaking with the individual, I feel the lorazepam is successful in achieving the goal of reducing anxiety.

 This exercise has impacted my clinical practice in regard to my knowledge of pharmacology. I am more aware of the mechanism of action for benzodiazepines and more specifically lorazepam. I also have a better understanding of interactions with drugs, foods, and herbals that may occur. I believe having a foundation of knowledge about this anxiolytic is very helpful in clinical settings because it may be a common drug I come across throughout my different placements. When entering the mental health rotation, it is possible I will see more of this drug to help reduce anxiety or treat insomnia. I believe I may see this drug more often in the surgical rotation as it can be used as a pre-anaesthetic. Having knowledge about the pharmacokinetics and pharmacodynamics of lorazepam will help me properly educate my patients to ensure they are safely taking lorazepam. It is important to have an understanding of how medications work and the effects they may have on the body, this will allow us to give adequate health teachings. Pharmacology can be a tough concept for students and even nurses to grasp, this exercise has helped me immensely with my understanding of drugs and how to research them.

Appendix

Pharmacotherapeutics

Uses

Anxiety disorders, panic disorders, sedation, seizure disorders0n 5rmyu

Doses

Oral, tablet, 0.5 mg, 1 mg, 2 mg

Sublingual, tablet, 0.5 mg, 1 mg, 2 mg

IM/IV, injectable solution, 2 mg/mL, 4 mg/mL

Pharmacokinetics

Absorption

Well absorbed after being orally administered, readily and rapidly absorbed with bioavailability of 90%

Distribution

Widely distributed, crossing blood-brain barrier, placenta, and enters breast milk, about 85% bound to plasma proteins

Metabolism

Almost completely metabolized by the liver through process of glucuronidation (conjugated)

Excretion

Excreted by the kidneys through urine (70-75%), feces, breast milk

Half life

10-16 hours

Onset

PO: 1 hour

IM: 15-30 minutes

IV: 5 minutes

Peak

PO: 2 hours

IM: 1- 1 ½ hours

IV: 5–10 min

Duration

PO: 12-24 hours

IM: 6-8 hours

IV: 6-8 hours

Special Considerations

Age

Pediatrics: can cause paradoxical excitation in children

Geriatrics: caution advised when administered through IV/IM, higher risk for experiencing apnea, bradycardia, cardiac arrest, hypotension, increase in sedation which results in increase for risk of falls

Gender

Pregnancy category D (risk to fetus; benefits may outweigh risks); drug crosses placental barrier and is excreted in breast milk

Breastfeeding mothers: excreted in breast milk, neonate has limited ability to metabolize drugs, short-term use relatively safe, taken chronically can accumulate in nursing child, lorazepam preferable (short-acting, low lipophilicity and no active metabolites)

Other Medical Diseases

Hepatic Encephalopathy: dosage should be adjusted as lorazepam can increase hepatic encephalopathy

Sleep apnea/ COPD: caution when taking lorazepam, can cause respiratory depression

Severe depression: may emerge or worsen during use of lorazepam

Open- Angle Glaucoma: may increase intraocular pressure

Hypersensitivity: to benzodiazepines or any of the components of benzodiazepines

Other Drugs

Alcohol: increasing sedation effects, increasing risk for respiratory depression/death 

Barbiturates: produce increased central nervous system depression

Clozapine: mix of drugs may cause sedation, hypotension, ataxia, delirium

Theophylline: reduce sedative effect of lorazepam

Digoxin: may contribute to toxicity by increasing serum digoxin level

Kava/Valerian/Chamomile: can have additive effects

Gotu Kola/Ma Huang: can reduce drug effectiveness

Inhibitors of CYP3A4: increase serum concentrations and effects

Inducers of CYP3A4: decrease serum concentrations and effects

Inhibitors of CYP2C19: increase effects metabolized by affected enzymes

Opioids: mixing of opioids and lorazepam may cause sedation, coma, death, respiratory depression

References

RxTx (2015, May). Benzodiazepines. Retrieved February 20, 2019, from http://www.myrxtx.ca.ezpxy.fanshawec.ca/search

Adams, M. P., Urban, C. Q., El-Hussein, M., Osuji, J., & King, S. (2010). Pharmacology of anxiety and sleep disorders. In Pharmacology for Nurses: A Pathophysiologic Approach (2nd ed., pp. 170-171). Pearson Canada.

Skidmore-Roth, L. (2019). Lorazepam. In Mosby’s 2019 Nursing Drug Reference (32nd ed., pp. 724-726). Elsevier.

Ativan C-IV (lorazepam). (n.d.). Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017794s044lbl.pdf