Ativan side effects and interactions, and how to avoid them

If you have anxiety, you’ve probably heard of Ativan. Still, you might not know that Ativan also helps with insomnia, it can prevent nausea during chemotherapy treatments, and it’s used to treat status epilepticus seizures. Ativan, a brand name of the medication lorazepam, is a quick-acting medication, with most people starting to feel its calming effects between 20 and 30 minutes after taking it. As with most medications, Ativan has side effects and it can interact with other drugs. In this article, we discuss the possible Ativan side effects, drug interactions, and warnings to safely use it. 

What is Ativan?

Ativan (lorazepam) is in a class of medication called benzodiazepines. It is available as a prescription drug. It’s approved in the U.S. for the following treatments: 

• Short-term relief of symptoms from anxiety disorders and anxiety-associated depression
• Management of anxiety disorders

Doctors sometimes prescribe it off-label, meaning that although it isn’t approved to treat a specific medical condition, anecdotal evidence has found it helpful. According to the National Center for Biotechnology Information, these conditions include:

• Alcohol withdrawal syndrome and delirium
• Panic disorders
• Preventing nausea during cancer treatment
• Muscle spasms
• Relaxation and sedation before anesthesia
• Psychogenic catatonia
• Short-term use for insomnia
• Status epilepticus seizures

Ativan is quick-acting. When taking orally, most people start to feel the effects in 20 to 30 minutes. Ativan is effective within one to three minutes when given intravenously. 

RELATED: Anxiety treatments and medications

Why is lorazepam a controlled substance?

There is a risk of Ativan abuse and dependence. The United States Food and Drug Administration (FDA) has labeled Ativan a Schedule IV controlled substance. There are five levels of controlled substances based on the drug’s risk of abuse or harm, such as if the drug has the potential to lead to psychological or physical dependence. Schedule I has the highest potential for drug abuse, such as heroin. These drugs have no accepted medical use and are not legal in the United States. Schedule V drugs have the lowest potential for abuse, such as certain cough syrups that contain codeine. Benzodiazepines such as Ativan are in Schedule IV, meaning they have a moderate potential for substance abuse, as well as having legitimate medical use. Other medications in this category include Xanax (alprazolam), Klonopin (clonazepam), and Valium (diazepam). 

Is Ativan a narcotic?

Although it is a controlled substance, Ativan is not a narcotic. Narcotics reduce a person’s perception of pain, while benzodiazepines have calming effects. Both narcotics and benzodiazepines have the potential to be habit-forming. Although medical practitioners consider Ativan safe and effective when used as directed, physical dependence can develop as quickly as two weeks, according to the National Alliance on Mental Illness (NAMI).

Common side effects of Ativan

Ativan’s side effects tend to be more severe with higher doses. Some of the most common side effects include:

• Dizziness
• Drowsiness or sleepiness
• Sedation
• Lightheadedness
• Unsteadiness
• Decreased ability to concentrate
• Muscle weakness
• Dry mouth

“Decreased blood pressure is a side effect of Ativan, but it is not prescribed for lowering blood pressure,” explains Amanda Brown, NP, a psychiatric mental health nurse practitioner at New York-Presbyterian Hospital and associate at Columbia University Irving Medical Center. 

Ativan can also cause sleep disturbances, erectile dysfunction, and changes in appetite. 

Ativan works by calming the nervous system to balance activity in the brain, promoting a relaxing, calming effect. It also raises dopamine, and when taken in high doses, feel-good neurotransmitters in the brain increase, causing a euphoric feeling, which is one of the reasons it is addictive. 

Serious side effects of Ativan

Some people could experience more severe side effects from Ativan use. These include:

• Shuffling walk
• Tremors or inability to sit still
• Fever
• Breathing problems
• Difficulty swallowing
• Skin rash or hives
• Yellowing of skin or eyes
• Irregular heartbeat 
• Memory loss or memory problems
• Disorientation
• Sleep apnea or worsening of sleep apnea

Most of the time, side effects lessen as the medication’s effect decreases, usually in six to eight hours. However, if you are experiencing severe side effects or effects do not go away within a few hours, you should seek medical attention. 

“Side effects that warrant stopping the medication include extreme sleepiness, memory loss, irritability, markedly impaired coordination, and dizziness,” Brown says. Because suddenly stopping Ativan can cause withdrawal symptoms, you should talk to your doctor before discontinuing it. 

Ativan warnings

Ativan is a short-term medication. When prescribed for daily use, the recommended course of treatment is four weeks or less. 

Ativan withdrawal symptoms

“Long-term use can lead to dependency and tolerance, meaning a person may need a higher dose to have the same effect or may experience withdrawal from not taking the medication,” says Wendi D. Jones, Pharm.D., a pharmacist in North Carolina. “Psychologically, it may be more difficult to go without the drug, leading to increased anxiety. Stopping the medication after a few weeks of use shouldn’t cause significant problems. However, if you have been using the medication for longer than two to four weeks, dependence can occur, and tapering off it could be required.” 

Depression

For some people, Ativan could exacerbate depression symptoms. Ativan is a central nervous system depressant. When it builds up in your system or if you take it at high doses, it’s possible for depression to worsen and even result in suicidal thoughts or feelings. The drug information outlined in the package insert indicates Ativan should only be used in patients with depression when the patient is also on antidepressant treatment. 

Age restrictions

Ativan is on the Beers Criteria Medication List of drugs that are potentially inappropriate for older adults. Older adults have increased sensitivity to benzodiazepines. In these patients, there is an increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes when Ativan is used. Despite being on the Beers List, Ativan is frequently prescribed to older adults. In these patients, the lowest possible dose should be used and the patient should be closely monitored. 

Because lorazepam is a sedative, you should not drive a car or operate machinery until you know how this medication affects you. 

Memory impairment

There is also conflicting information as to whether Ativan causes or is a risk factor for memory impairment or Alzheimer’s disease. One study found the benzodiazepines could be a risk factor for dementia. And another study, published in 2014, found an association between taking lorazepam and the risk of Alzheimer’s disease. However, more recent research, published in 2016, showed that the risk of dementia was only slightly higher in people taking low doses of benzodiazepines, and it was not present in those taking it at higher doses.

Respiratory depression

Benzodiazepines can cause respiratory depression, or hypoventilation, when used on their own, and even more when combined with another central nervous system (CNS) depressant. This breathing disorder causes slow, ineffective breathing, creating a higher level of carbon dioxide and a lower level of oxygen in your body.

Benzodiazepines such as Ativan can also cause respiratory depression when combined with other sedating medications or substances such as alcohol, muscle relaxants, sedating antihistamines, antipsychotics, anticonvulsants, and antidepressants. Always consult your healthcare provider to make sure that Ativan is safe in combination with other medications you take.

Pregnancy and breastfeeding

If you are pregnant or planning to become pregnant, seek medical advice before taking this medication. Animal studies have shown occasional abnormalities in the fetus. There is an increased risk of malformations from tranquilizers during the first trimester. The use of Ativan during the third trimester is also associated with an increased risk of neonatal withdrawal. Lorazepam may pass to babies in breast milk and may cause sedation and irritability in the baby. If you are breastfeeding, consult your healthcare provider.

Ativan interactions

“Alcohol and opioids should be avoided when taking Ativan,” says Dr. Jones, “In general, anything that makes you feel tired, including CBD oil and melatonin, need to be taken carefully until you know how your body reacts. There are several medications that can increase the adverse or toxic effects of lorazepam. It is always good to ask your pharmacist if something is safe for you to take, including prescription, over-the-counter, and herbal medicines.” 

Drug-drug interactions

Before taking Ativan, or any medication, you should tell your doctor about all medications—prescription or over-the-counter, supplements, and vitamins—you are taking especially:

• Anticonvulsants
• Antidepressants
• Asthma medications: theophylline
• Cold medicine
• Gout medication: probenecid
• Medications for Parkinson’s disease: Rytary, Sinemet, and Stalevo (levodopa)
• Muscle relaxants
• Opioid pain medications
• Oral antifungals
• Oral contraceptives (birth control pills)
• Sedatives, tranquilizers, or sleeping pills
• Sedating allergy medicine/antihistamines
• Pain medications or cough medications that contain codeine

If you are taking any of these medications, your doctor might want to adjust your dosage, switch to a different medicine, or closely monitor you for side effects and adverse reactions. 

Food-drug interactions

You should not consume grapefruit or grapefruit products while taking this medication as this can increase the effects and lead to toxicity or adverse reactions. 

You should not drink alcohol while taking it as you can experience life-threatening side effects.

While there are no specific warnings against drinking coffee or other foods and beverages containing caffeine, it is essential to remember that caffeine is a stimulant and could potentially counteract the effects of lorazepam. 

How to avoid Ativan side effects

Side effects, such as tiredness, usually start shortly after taking the medication, often within 30 minutes of taking the medication. They generally lessen as the effects of the drug decrease, typically between six and eight hours after taking it. Some people also notice that side effects decrease as they continue taking the medication, and their body adjusts to it, for example, they might not feel as tired after taking it regularly for several days or weeks. 

1. Take Ativan according to your doctor’s instructions.

Taking the correct Ativan dosage helps reduce the side effects you might experience. Some people take them “as needed,” which means only at times you feel anxious, and others take them at regular intervals throughout the day to keep anxiety symptoms at bay. If you are experiencing side effects, talk to your doctor about whether changing the time you take the medication could reduce your discomfort. 

Ativan is available in different forms and doses:

• Intramuscular injection: 2 mg/ml, 4 mg/ml
• Intravenously: 2 mg/ml, 4 mg/ml 
• Oral tablet: 0.5 mg, 1 mg, 2 mg

You should start at a low dose and slowly work your way up, assuring you are taking the lowest dose that provides a benefit to you. The Prescriber’s Digital Reference (PDR) suggests the following doses for anxiety:

Ativan dosage for anxiety by age
	Starting oral dosage	Maximum oral dosage
Children ≤ 11 years old	Determined by child’s age, weight, and health history.
Adolescents 12+ years	2-3 mg per day divided into 2-3 doses throughout the day; may increase gradually as needed and as tolerated	Up to 10 mg per day as needed, divided into several doses (usual maximum needed is 6 mg/day in divided doses)
Adults	2-3 mg per day divided into 2-3 doses throughout the day; may increase gradually as needed and as tolerated	Up to 10 mg per day, divided into several doses (usual maximum needed is 6 mg/day in divided doses)
Geriatric adults	1-2 mg per day divided into 2-3 doses throughout the day; may increase gradually as needed and as tolerated	Up to 6 mg per day (2 mg per day in long term care facility residents). There’s an increased risk of toxicity in this population, therefore, small, gradual increases are best.

For insomnia, the recommended adult dosage starts at 2 mg at bedtime, to be increased to 4 mg, if needed, with the course of treatment four months or less. 

2. Take Ativan with food.

Most people do not experience stomach pain or upset when taking Ativan; however, if you do, it might help to take it with food. 

3. Do not suddenly stop taking Ativan.

Symptoms from withdrawal from Ativan can be more uncomfortable than the side effects. You should not stop taking the medication suddenly, especially if you are taking it regularly. Withdrawal symptoms include rebound anxiety, restlessness, tremor, sweating, agitation, insomnia, and possibly seizures. These symptoms begin within one to two days after your last dose and can last for seven days or more, depending on how long you have been taking it. It is best to taper how much and how often you take it slowly. 

Your doctor will work with you to set up a safe tapering schedule. The San Mateo County Health Department suggests two methods of tapering:

• A reduction of 25% of the initial dose every two weeks, or 
• Decreasing the dose by 25% the first week, 25% the second week, and then by 10% each week until you have discontinued the medication 

The tapering process can take several weeks to a few months to completely stop the medication. Doing it this way eliminates or dramatically reduces any withdrawal symptoms you experience. 

4. Ask your doctor about switching to a different medication.

Your healthcare provider might suggest trying other anxiety medications in place of Ativan. Some antidepressants can reduce symptoms of anxiety. These include:

• Cymbalta (duloxetine) 
• Silenor (doxepin) 
• Lexapro (escitalopram) 
• Paxil, Paxil CR, Pexeva, Brisdelle (paroxetine) 
• Effexor XR (venlafaxine) 

There are also other benzodiazepines, which include:

• Xanax (alprazolam) 
• Valium (diazepam) 
• Klonopin (clonazepam)

Everyone reacts to medication differently. What works best for one person may not work for another. It is best to work closely with your doctor and learn about all of your treatment options so you can find the drug that works best for you.