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Midazolam vs Ativan
Introduction
For patients struggling with anxiety disorders or enduring severe bouts of insomnia, certain medications that affect the concentrations of compounds in the brain associated with calmness and relaxation can be beneficial. Midazolam and Ativan (also known as Lorazepam) are two such drugs frequently administered for these conditions. Both belong to a class of drugs known as benzodiazepines, which work by enhancing the effect of a neurotransmitter called gamma-aminobutyric acid (GABA) resulting in sedative, anxiolytic, muscle relaxant and anticonvulsant actions. Midazolam is noted for its fast onset but has a shorter duration than Ativan, making it commonly used for procedural sedation purposes including dental procedures or before surgery. On the other hand, Ativan's longer lasting effects make it more suitable for managing persistent symptoms of anxiety or aiding sleep over a longer period.
Midazolam vs Ativan Side By Side
| Attribute | Versed | Ativan |
|---|---|---|
| Brand Name | Versed | Ativan |
| Contraindications | Should not be taken with azole antifungals (e.g., itraconazole), macrolide antibiotics (e.g., erythromycin), or protease inhibitors for HIV (e.g., ritonavir). | Should not be taken with azole antifungals (e.g., itraconazole), macrolide antibiotics (e.g., erythromycin), or protease inhibitors for HIV (e.g., ritonavir). |
| Cost | Approximately $1.87 per day for brand name; $.60 - .90 per day for generic | Approximately $7.33 per day for brand name; $.50 to $2.00 per day for generic |
| Generic Name | Midazolam | Lorazepam |
| Most Serious Side Effect | Severe allergic reactions, vision changes, unusual behavior, altered heart rate, low sodium levels. | Allergic reactions, mood or behavior changes, symptoms resembling a seizure, sudden restlessness or excitement, hallucinations, confusion. |
| Severe Drug Interactions | Increased side effects with certain inhibitors like azole antifungals, macrolide antibiotics, or protease inhibitors for HIV. | Increased side effects with certain inhibitors like azole antifungals, macrolide antibiotics, or protease inhibitors for HIV. |
| Typical Dose | Oral dosages range from 7.5-15mg per day for adults; 0.125-0.25mg/kg every six hours for children aged six months to 16 years. | 1-2 mg per day, divided into two or three doses. Maximum daily dose commonly used is 6mg. |
What is Midazolam?
Midazolam (marketed under brand names like Versed) is a fast-acting drug from the benzodiazepine class of medications, which represented a significant advancement over the first generation of antianxiety drugs known as barbiturates. Midazolam was first approved by the FDA in 1985. It boosts the effect of gamma-aminobutyric acid (GABA), inhibiting certain brain signals and causing a calming effect on your mind and body. It's often used for short-term relief from severe anxiety or agitation, especially before medical procedures or surgeries.
On the other hand, Ativan - also known as lorazepam - while still being part of the same medication class as midazolam, has slightly different characteristics. For instance, it usually takes longer to start working but its effects can last more than midazolam's ones. This makes Ativan an ideal choice for patients who require long-lasting relief from persistent symptoms of anxiety disorders.
Both medications have similar side effects due to their identical class; however, they may vary based on individual tolerance and dosage levels.
What conditions is Midazolam approved to treat?
Midazolam is approved for the treatment of various conditions, including:
- Preoperative sedation, anxiolysis and amnesia (memory loss)
- Acute agitation or delirium
- Seizures that are resistant to other treatments
- Induction of general anesthesia in combination with a pain reliever.
Ativan (lorazepam) is also used for similar purposes, but additionally can be prescribed to treat:
- Anxiety disorders or short-term relief from symptoms of anxiety
- Insomnia caused by anxiety or stress
How does Midazolam help with these illnesses?
Midazolam helps to manage anxiety and induce sleep by increasing the amount of gamma-aminobutyric acid (GABA) in the brain. It does this by enhancing the effect of GABA, an inhibitory neurotransmitter that diminishes neuronal excitability throughout the nervous system, thus promoting sedation and relaxation. Levels can be maintained higher for longer periods of time providing relief from symptoms such as insomnia or acute stress reactions. This neurotransmitter plays an important role in mood regulation, sleep patterns, cognition and memory among other things. It is thought that individuals with high levels of anxiety or difficulty sleeping have imbalances in their GABA systems. Therefore, by augmenting GABA function, Midazolam lessens these negative effects and helps patients manage their condition more effectively.
What is Ativan?
Ativan, a brand name for lorazepam, is a benzodiazepine that enhances the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at GABA-A receptors. This action results in its several therapeutic uses including anxiety disorders, trouble sleeping, active seizures including status epilepticus and alcohol withdrawal symptoms. Ativan was first approved by the FDA in 1977.
As Ativan is not an SSRI antidepressant, it does not inhibit serotonin reuptake. Its lack of action on serotonin means that its side-effect profile is also different to SSRIs such as Prozac. Specifically, it has more pronounced sedative effects which makes it useful for insomnia treatment but requires caution due to potential dependency issues.
The effects on GABA can be beneficial especially in patients who do not respond well to "typical" antianxiety drugs or other treatments for conditions like epilepsy and alcohol withdrawal syndrome.
What conditions is Ativan approved to treat?
Ativan is a highly regarded medication approved for the management of:
- Anxiety disorders or for short-term relief of symptoms of anxiety
- Preoperative sedation and help with anesthesia
- Acute seizures to control an ongoing series of seizures, making it a vital asset in acute care settings.
How does Ativan help with these illnesses?
Ativan, known generically as lorazepam, is a medication that affects gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain which plays roles in anxiety reduction, sedation and memory formation. This drug works by enhancing the effects of GABA in the brain to promote calmness and reduce excitability. Ativan has been used widely to treat anxiety disorders, insomnia due to stress or anxiety and also for preoperative sedation. Its actions on GABA receptors may contribute significantly to its efficacy as an anti-anxiety agent. Like midazolam, it falls under the class of benzodiazepines but it lasts longer in your system making it effective for conditions requiring prolonged effect like chronic anxiety disorders. In situations where a patient does not respond well to shorter acting benzodiazepines such as midazolam or requires continuous effect over a period of time, Ativan might be considered.
How effective are both Midazolam and Ativan?
Both midazolam and lorazepam (Ativan) have well-established histories of success in treating patients with various conditions requiring sedation, including preoperative anxiety, insomnia, and seizure disorders. They were approved by the FDA just a few years apart from each other. As they both belong to the benzodiazepine class of drugs, they act on similar neurotransmitters but may be prescribed under different circumstances due to their pharmacokinetic profiles.
The effectiveness of midazolam and lorazepam was directly studied in several clinical trials; these two drugs exhibited similar efficacy in managing symptoms such as anxiety or seizures along with promising safety profiles. However, the onset of action for IV midazolam is typically faster than that for IV lorazepam making it a preferred choice for procedures requiring rapid sedation or acute seizure management.
A 2005 review showed that intramuscular midazolam provides effective conscious sedation and amnesia during minor surgical procedures similarly to oral diazepam but without any significant cardiorespiratory side effects. The same study reports that it has become one of the most widely used benzodiazepines worldwide particularly because its water-soluble formulation makes it suitable for multiple routes of administration.
On the other hand, a 2010 meta-analysis indicated that lorazepam seems more effective than placebo at reducing symptoms associated with panic disorder while maintaining an acceptable safety profile. Furthermore, Lorazepam’s longer duration of action compared to midazolam often positions it as first-line treatment for conditions like chronic insomnia where sustained relief is required throughout night-time hours. Despite this advantage over shorter-acting alternatives like midazolam, data confirming its superiority are still lacking.
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At what dose is Midazolam typically prescribed?
Oral dosages of Midazolam range from 7.5-15mg per day for adults, although studies show that a dose as low as 7.5 mg/day can be sufficient to treat severe anxiety and insomnia in most individuals. For children aged six months to 16 years old, the recommended oral dosage is typically between 0.125-0.25mg/kg every six hours, but should not exceed a total daily dose of 1mg/kg or 40mg, whichever is lower. Like Prozac and Wellbutrin, the dosage can be increased after a few weeks if there's no response; however, any increase should always be under close medical supervision due to potential respiratory depression risk associated with benzodiazepines like Midazolam.
At what dose is Ativan typically prescribed?
Ativan treatment typically begins with a dose of 1-2 mg per day, divided into two or three doses throughout the day. This dosage can gradually be increased depending on the patient's response to the medication and their tolerance level. The maximum daily dose commonly used is 6mg, split into three separate doses of 2mg each and spaced appropriately apart during a 24-hour period. If after several weeks there appears to be limited effectiveness, your physician might consider increasing the dosage but it should never exceed more than what your healthcare provider prescribes due to potential risks for dependency and severe withdrawal symptoms.
What are the most common side effects for Midazolam?
Midazolam and Ativan, both benzodiazepines used to manage anxiety and induce sedation, can have similar side effects. However, each individual may respond differently. The most common side effects associated with midazolam include:
- Drowsiness or sleepiness
- Nausea or vomiting
- Dizziness or lightheadedness
- Amnesia (memory problems)
- Impaired motor functions (balance issues, lack of coordination)
- Slurred speech
On the other hand, those using Ativan might experience:
- Sleepiness/drowsiness
- Dizziness
- Unsteady balance
- Memory problems
- Hangover feeling (especially the day after use)
It's important to note that while these are common adverse reactions for these medications, not everyone will experience them. Always consult your healthcare provider regarding potential risks before starting any new medication regimen.
Are there any potential serious side effects for Midazolam?
Midazolam and Ativan are two medications commonly used to treat anxiety and insomnia, but they can have different side effects. For Midazolam, some serious side effects could include:
- Severe allergic reactions; signs may include hives, difficult breathing or swallowing, swelling in your face or throat.
- Vision changes such as blurred sight or seeing halos around lights.
- Unusual behavior like agitation or hallucinations.
- Altered heart rate – it can be too fast, too slow or irregular.
- Low sodium levels - symptoms might involve headache, confusion, slurred speech, severe weakness, vomiting and loss of coordination.
Ativan also has significant potential side effects which include:
- Serious skin reactions causing a rash that blisters and peels
- Shallow breathing
- Aggression or violent outbursts -Muscle stiffness or twitching -Balance issues leading to falls
If you are experiencing any of these symptoms after taking either Midazolam or Ativan it's important to seek medical help immediately.
What are the most common side effects for Ativan?
Ativan, a commonly prescribed benzodiazepine, has its own set of potential side effects. It may cause:
- Dry mouth or excessive saliva production
- Constipation
- Blurred vision
- Changes in appetite
- Drowsiness and light-headedness
- Headache or dizziness
- Feeling unsteady or loss of coordination
- Nausea or vomiting
- Skin rash
- Sleep disturbances such as insomnia
It's also worth noting that Ativan could lead to feelings of restlessness, excitability, and even hallucinations in some cases. In rare instances, it can trigger muscle weakness and pain. Users have reported increased urination as well.
Are there any potential serious side effects for Ativan?
Ativan, while generally safe and effective for managing anxiety, can in some cases cause serious side effects. Look out for the following symptoms:
- Signs of an allergic reaction such as hives; difficulty breathing or swallowing; swelling in your face, lips, tongue or throat
- Changes in mood or behavior including thoughts of hurting yourself
- Symptoms resembling a seizure (convulsions)
- Sudden restlessness or excitement
- Hallucinations, confusion or changes in vision
- Unusual fatigues, dark urine and stomach pain which could be signs of liver problems
- Rapid heart rate or irregular heart rhythm
These symptoms are not common but if you experience them you should stop taking Ativan and seek immediate medical attention.
Contraindications for Midazolam and Ativan?
Similarly, Midazolam and Ativan, along with most other benzodiazepine medications, may worsen symptoms of depression in some individuals. If you notice your depression worsening, or an increase in suicidal thoughts or behavior while on these medications, please seek immediate medical attention.
Neither Midazolam nor Ativan should be taken if you are currently using or have recently been taking certain types of inhibitors like azole antifungals (e.g., itraconazole), macrolide antibiotics (e.g., erythromycin), or protease inhibitors for HIV (e.g., ritonavir). These can slow down the removal of midazolam and lorazepam from your body leading to increased side effects. Always inform your doctor about which medications you are currently taking; such inhibitors will require a period to clear from the system to prevent dangerous interactions with both Midazolam and Ativan.
How much do Midazolam and Ativan cost?
For the brand name versions of these drugs:
- The price for 30 tablets of Ativan (1 mg) averages around $220, which works out to about $7.33/day.
- The price for 5 ampules of midazolam (15mg/3ml) is approximately $28, which translates to roughly $1.87 per day assuming one ampule is used daily.
If you are in a higher dosage range for Ativan (e.g., 2 mg/day or higher), then brand-name midazolam tends to be less expensive on a per-day treatment basis. However, it's crucial to remember that cost should not be your primary consideration in determining which drug is right for you.
As far as generic options go:
- Lorazepam (generic Ativan), available in packs ranging from 30 and above tablets, costs between $.50 and $2.00 per day depending on the dosage taken.
- Midazolam also has cheaper generic options with similar dosages costing around $.60 - .90 per day.
Again, prices will vary depending upon where you buy these medications and whether or not they're covered by your insurance plan.
Popularity of Midazolam and Ativan
Midazolam, in generic form and brand names such as Versed, was estimated to have been prescribed about 4.5 million times in the US in 2020. Midazolam is often used for sedation before surgeries or medical procedures, and it accounted for approximately 9% of all benzodiazepine prescriptions last year.
On the other hand, Lorazepam (commonly known by its brand name Ativan) was prescribed more than twice as frequently. In 2020 alone, lorazepam prescriptions exceeded a staggering number of nearly 14 million people in the USA. It accounts for close to one-fourth of all benzodiazepine prescriptions across the country. While both midazolam and lorazepam are classified as short-to-intermediate-acting benzodiazepines with similar uses including treatment of anxiety disorders, insomnia, epilepsy among others; their clinical use differs significantly due to varying potency levels. Over time however, prescription rates for both medications have remained relatively steady over the past decade.
Conclusion
Both midazolam and Ativan (lorazepam) have long-standing records of usage in the management of anxiety disorders, insomnia, and seizures. They are backed by numerous clinical studies indicating that they are more effective than placebo treatments. Both drugs belong to the benzodiazepine class and act on gamma-aminobutyric acid (GABA) receptors in the brain, but they may be prescribed under different circumstances due to their pharmacokinetic profiles.
Ativan has a longer duration of action compared with midazolam and is often used for long-term treatment of chronic conditions such as generalized anxiety disorder or sleep disturbances. On the other hand, midazolam's rapid onset and short half-life make it particularly suitable for acute situations like preoperative sedation or brief episodes of severe agitation.
Both medications are available in generic form which can lower costs significantly especially for patients who must pay out-of-pocket. Both Ativan and midazolam require careful monitoring as physical dependency can occur even after short term use.
The side effect profile is similar between these two drugs; they both carry risks such as drowsiness, dizziness, confusion and memory problems among others. With both medications there’s also a risk for paradoxical reactions including restlessness or mood changes. For either drug, patients should seek immediate medical attention if experiencing difficulty breathing or signs of an allergic reaction.
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Refrences
- POHLMAN, A. S., SIMPSON, K. P., & HALL, J. B. (1994, August). Continuous intravenous infusions of lorazepam versus midazolam for sedation during mechanical ventilatory support. Critical Care Medicine. Ovid Technologies (Wolters Kluwer Health).http://doi.org/10.1097/00003246-199408000-00007
- Morita, T., Tei, Y., & Inoue, S. (2003, April). Correlation of the Dose of Midazolam for Symptom Control with Administration Periods. Journal of Pain and Symptom Management. Elsevier BV.http://doi.org/10.1016/s0885-3924(02)00683-8
- Kensche, M., Sander, J. W., & Sisodiya, S. M. (2010, December 15). Significant hypotension following buccal midazolam administration. Case Reports. BMJ.http://doi.org/10.1136/bcr.09.2010.3371
- Picone, D. A., D'Mello, D. A., Foote, M. L., & Msibi, B. (1993, January). A review of the utilization of sedative-hypnotic drugs in a general hospital. General Hospital Psychiatry. Elsevier BV.http://doi.org/10.1016/0163-8343(93)90091-2
- Nordt, S. P., & Clark, R. F. (1997, May). Midazolam: A review of therapeutic uses and toxicity. The Journal of Emergency Medicine. Elsevier BV.http://doi.org/10.1016/s0736-4679(97)00022-x