Approved Hospital Formulary
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Approved Hospital Formulary
1/4/24 Benzodiazepine Shortage Recommendations
January 4, 2024
From: "Brian Boyett" <brian.boyett@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>
Sent: Thursday, January 4, 2024 2:00:59 PM
Subject: Benzodiazepine Shortage Recommendations
To: "Pharmacists" <grp_allpharm@hhsys.org>
Sent: Thursday, January 4, 2024 2:00:59 PM
Subject: Benzodiazepine Shortage Recommendations
Pharmacists,
As a clarification to the previous email and to provide more guidance during the ongoing LORazepam (Ativan) and diazePAM (Valium) shortages, some common benzodiazepine equivalents are listed below:
- LORazepam 1 mg IV/IM ~ LORazepam 1 mg PO/SL soln (approved for automatic interchange when ordered pre-procedure)
- NOTE: The oral concentrate solution may be given sublingually
- LORazepam 1 mg IV/IM ~ ALPRAZolam 0.5 mg PO
- diazePAM 5 mg IV/IM ~ LORazepam 1 mg IV/IM
- LORazepam 1 mg IV/IM ~ midazolam 1-2 mg IV/IM
- A dosing range of midazolam of 2 mg-5mg IV has been found to be effective, but it is generally recommended to start with the lower end of the range for most indications (unless patient is being intubated or in surgery)
A few notes about using midazolam:
- Midazolam IV push is restricted to ICU patients and procedural areas (intubated).
- Midazolam infusions may be given outside the ICU for end-of-life comfort measures (see Injectable Benzodiazepine Guidelines and the Titration and IV Medication Use Guidelines)
- It has a quicker onset and shorter duration than LORazepam which should be kept in mind based on indication (e.g. midazolam should not be given prior to patient transport to procedural area due to the risk of respiratory depression)
- It is a highly lipophilic drug compared to other benzodiazepines which can lead to more CNS depression
- Use caution in special populations like the elderly, obese, and patients with altered kidney or hepatic function, half life is increased
Please use clinical judgement when converting between benzodiazepines. A conservative conversion may be appropriate in certain patients (especially those on the floor) and the oral route is preferred when possible.
Feel free to reference this online conversion calculator (https://clincalc.com/Benzodiazepine/) if you desire and, as always, cross check with multiple sources when asked for clinical recommendations.
Drug Information is currently putting together a comprehensive guide for management of benzodiazepine drug shortages. This will be emailed out and posted to FormWeb when complete. Let me know if you have any questions or concerns.
Thanks,
Brian Boyett, Pharm. D., BCPS
Supervisor, Pharmacy Professional Services
Huntsville Hospital
Office: 5-4522 | ASCOM: 7-4665
Supervisor, Pharmacy Professional Services
Huntsville Hospital
Office: 5-4522 | ASCOM: 7-4665
From: "David Collette" <david.collette@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>, "Nurse Managers" <grp_allnursemgrs@hhsys.org>, "Charge Nurses" <grp_allchgnurses@hhsys.org>, "All Unit Directors" <allunitdirectors@hhsys.org>
Cc: "Pharmacy Buyers" <pharmbuyers@hhsys.org>
Sent: Friday, December 29, 2023 10:05:18 AM
Subject: LORazepam IV to PO for pre-procedural orders
To: "Pharmacists" <grp_allpharm@hhsys.org>, "Nurse Managers" <grp_allnursemgrs@hhsys.org>, "Charge Nurses" <grp_allchgnurses@hhsys.org>, "All Unit Directors" <allunitdirectors@hhsys.org>
Cc: "Pharmacy Buyers" <pharmbuyers@hhsys.org>
Sent: Friday, December 29, 2023 10:05:18 AM
Subject: LORazepam IV to PO for pre-procedural orders
The following email was sent to the medical staff this morning. Please let me know if you have any questions or concerns:
The injectable LORazepam shortage continues to worsen. As announced last week, we are reserving injectable LORazepam (and diazepam) for treatment of seizures. However, many power plans contain orders for pre-procedural doses of injectable LORazepam and are threatening our supply. Effective immediately, pharmacists will automatically convert injectable doses of LORazepam to PO LORazepam on a 1:1 basis when ordered pre-procedure.
Another issue that has arisen is the ordering of midazolam (Versed) in pre-procedural situations. Versed is only approved for use in ICUs and in situations where "comfort measures only" are appropriate. Procedural use is only allowed when the patient is constantly monitored by qualified personnel; as such, midazolam is not appropriate for pre-procedural use. An option in these situations is to convert midazolam IV to LORazepam PO on a 5:1 bases (5 mg midazolam IV ≈ 1 mg LORazepam PO). Another option is alprazolam (Xanax) 0.5 mg PO. Pharmacists will attempt to contact the prescriber for clarification when midazolam is ordered in this situation.
Thank you for your support as we work through this ongoing shortage. There is no definitive resolution date, but late January to late February have been mentioned. If you have any questions or concerns, please contact your unit-based pharmacist or David Collette.