A Practitioner’s Guide to Prescribing Lorazepam for Adults with Intellectual Disabilities

Abstract

We developed this lorazepam guideline using drug prescribing ­information and reviewing the available literature on relevant neuropsychiatric disorders in populations without intellectual disabilities because of the dearth of available literature on the population with intellectual disabilities. This guideline includes indications; contraindications; assessments prior to and during treatment; dosing with particular focus on dosing modifications required by drug–drug interactions, personal characteristics, or genetic variants; and adverse drug reactions. The procedures contained in this guideline may not fully account for all of the possible risks of treatment in this population because of the limited studies available; thus, there will be a need to periodically update this guideline as new information becomes available. Nevertheless, we believe that this guideline provides a useful resource for clinicians who treat anxiety or catatonia in adult individuals with intellectual disabilities. A lorazepam drug utilization review that summarizes this guideline is described.

Appendix Drug Utilization Review: Lorazepam

DRUG UTILIZATION REVIEW CRITERIA				CRITERIA MET
LORAZEPAM FOR ADULT INDIVIDUALS WITH IDs				YES	NO	NA
1) Indication: Check one of the following indications for use
	Anxiety disorders.
	Other (including ethanol withdrawal, insomnia, ­catatonia, and antipsychotic-induced akathisia): Specify_______________________. When lorazepam is used for off-label indications, the chart will specifically include an explanatory note (Y___ N___).
To meet indication criteria, at least one indication is present and documented.					
2) Dose:_____
	In chronic dosing, dose is divided in 2–3 administrations (Y__, N___) or justification is provided (Y__).					
	Dose was individualized according to patient response.					
	The dosage was ≤ 10 mg/day (Y__, N___) unless ­recommended otherwise by a consultant with expertise in the area (Y__).					
	Taking rifampin__ or oral contraceptives____. The chart documents the interaction (Y___ N___). The dosage of lorazepam may need to be increased when an inducer was added and the discontinuation of the inducer may need to be followed by a decrease of lorazepam dosage.					
	Taking phenytoin__, carbamazepine__, phenobarbital__, or primidone__. The chart documents the possibility of an interaction (Y___ N___) since these drugs may be inducers of lorazepam metabolism.							
	Taking inhibitors of lorazepam metabolism: valproate____ or probenecid___. The chart documents the interaction (Y___ N___). The dosage of lorazepam may need to be decreased when an inhibitor is added and the ­discontinuation of the inhibitor may need to be followed by an increase of lorazepam dosage.					
	Renal impairment_____. The chart documents lower doses and longer period between doses (Y___ N___).					
	Elderly patient. The chart documents lower initial and maximum doses The initial dose was ≤ 2 mg (Y___ N___) and the total daily doses ≤ 4 mg/day (Y___ N___).					
	Gilbert syndrome___. The chart documents lower doses (Y___ N___).					
To meet dose criteria all are Yes or NA.					
3) Relative contraindications: Check any present
	Pregnancy (Category D) or breast-feeding.
	Elderly or debilitated.
	Hepatic or renal impairment.
	Compromised respiratory function (e.g., COPD, ­sleep-apnea syndrome, limited pulmonary reserve).
	Impaired gag reflex or swallowing problems.
	Depression with suicide risk. Be sure patient is taking appropriate antidepressant treatment.
	History of drug dependence or alcoholism.
If any of the above are checked, rationale is documented in chart to meet relative contraindication criteria. If none are present check NA.						
4) Baseline monitoring study only for patients with chronic kidney disease or elevations in serum creatinine levels:
	Creatinine clearance.
Answer Yes or No. If information is not applicable check NA.						
5) Baseline monitoring study only for female patients with potential for being pregnant:
	If a female patient has potential to be pregnant, a pregnancy test is completed.
Answer Yes or No. If information is not applicable check NA.						
6) Discontinuation:
	Lorazepam is or was withdrawn slowly to minimize the potential of increased seizure frequency (Y___ N___). Abrupt withdrawal was justified by a major medical reason (Y___ N___).					
7) Adverse drug reactions (ADRs) due to lorazepam: Check left boxes to indicate which ADRs are present.
7.1) Common ADRs:
	Sedation, drowsiness, memory difficulties, fatigue, muscle weakness, or cognitive impairment.		Common in patients with IDs: aggression, irritability, hyperactivity, or agitation.
7.2) Relatively uncommon ADRs:
	Dysarthria, confusion, abnormal coordination, ataxia, depression or worsening of mood, slurred speech, dizziness, or tremor.		Dry mouth, constipation, or nausea.
	Paradoxical reaction including increased talkativeness, emotional release, excitement, or excessive movements.		Psychological or physical dependence.
	ADRs due to rapid decrease or abrupt withdrawal include agitation, heightened sensory perception, paresthesias, muscle cramps, muscle twitching, diarrhea, reduced concentration, worsening of mood, anxiety, nervousness, restlessness, sleeping difficulties, insomnia, tremors, or in rare cases, seizures and hallucinations.		Benzodiazepine intoxications manifest as intoxication with other CNS depressants (e.g., alcohol).
	Worsening of swallowing problems.		Other_____________
7.3) Potentially lethal ADRs:
	Suicidal ideation or behavior.
Answer Yes (intervention or benefit/risk discussion after ADRs developed) or No (neither intervention nor benefit/risk discussion after ADRs developed) or NA (no abnormality developed).