A Member of DOCS Education asks:
I have a 61 year old, 175 lbs female patient requiring a long sedation appointment. She is currently taking Advair®, Cartia XT®, losartan HCT and fenofibrate. Due to the medication interactions we cannot use diazepam or triazolam. Would it be possible for me to use lorazepam the night before, and if so, at what dosage should it be administered? Then at what incremental and loading dose should the lorazepam be given an hour prior to the appointment? After assessing the patient on arrival, what dose of hydroxyzine should be given? Finally, what incremental doses of lorazepam should be given at what intervals?
Since I have only used triazolam for my sedation cases, I am not sure of the protocol to follow. The patient also suffers from claustrophobia, which may impede the use of nitrous oxide.
Dr. Anthony Feck, Dean of DOCS Education Faculty, responds:
Lorazepam should not be used the night before the appointment. Unlike diazepam, which is ideally suited for pre-appointment dosing due to its low efficacy and long half-life, lorazepam has a significantly higher efficacy and an intermediate half-life. When diazepam is not appropriate, do not prescribe an alternative.
With this particular patient, I would recommend a 2mg loading dose of lorazepam. The initial assessment and subsequent re-assessment doses of lorazepam, as well as the initial assessment dose of hydroxyzine will depend on how the patient presents and responds to previous doses of sedative medication. The doses of lorazepam can be up to 4 mg depending on how much CNS depression is observable. The patient should be assessed no sooner than 30 minutes after the previous dose. The TOP dose for lorazepam for this patient is 6.6 mg. Once the patient is sedated appropriately, no further doses of lorazepam should be administered. Hydroxyzine would be administered in a single dose at an initial assessment of up to 100 mg.
The member of DOCS Education replies:
Thank you very much for your input. Should I give the lorazepam sublingually? I'm assuming at assessment that I would give the hydroxyzine first and the sublingual lorazepam second. Her previous dentist used IV sedation, so this may be tricky to get her where she wants to be. If I give her 2mg of lorazepam and 50mg of hydroxyzine and after 45 minutes and she is not sedated enough, could I still use 1 or 2 mg of lorazepam and maybe 25mg of hydroxyzine? After using triazolam for the last 11 years, this one dose concept is not working for me.
Dr. Jerome Wellbrock, DOCS Education faculty, adds:
Lorazepam is not given sublingually. If you are incrementally dosing the patient you may give an additional dose of lorazepam after re-evaluating your level of sedation. Hydroxyzine, however, is only given once. Make sure to calculate TOP DOSE for your patient prior to giving any sedation medications. Dose low and closely monitor your patient.
