Lorazepam-induced Severe Hypotension in a Case of Catatonia

Dear Editor, We wish to report a rare and clinically significant adverse reaction of lorazepam in a patient with catatonia. A 47-year-old female with no prior history of psychiatric or medical illness presented with a 10-day history of reduced interaction, decreased sleep, refusal of food intake, posturing, and reduced mobility. Initial evaluation revealed normal vital signs, including a blood pressure of 116/70 mmHg. A provisional diagnosis of catatonia was made. The Bush–Francis Catatonia Rating Scale, which is a standardized, widely used scale for the identification and quantification of signs of catatonia, was administered. It consists of 23 items and has good interrater reliability.[1] The score on Bush–Francis Catatonia Rating Scale was found to be 12, indicating catatonia (mutism 2, posturing 2, immobility 1, staring 2, negativism 1, withdrawal-2, combativeness -2). Lorazepam challenge test was planned. Lorazepam 4 mg intravenous (IV) was administered slowly to the patient over 2 min. Immediately following the injection, the patient became unresponsive with shallow respiration and hypotension (70/50). She was transferred to the emergency department, where intravenous fluids and hydrocortisone were administered. Her blood pressure improved transiently to 90/60 mmHg but dropped further within 4 h to <60 mmHg systolic. A noradrenaline infusion was started. By the next day, her vital signs stabilized. No other medications had been received by the patient prior to the reaction, and laboratory investigations ruled out sepsis, electrolyte imbalances, or cardiopulmonary pathology. Naranjo’s Adverse Drug Reaction Probability Scale is a commonly used questionnaire to assess the likelihood of an adverse reaction caused by drug. It has 10 items.[2] This scale was applied, and the score was found to be 7, indicating the probability of adverse effects due to the stated drug (lorazepam). On further evaluation, there was a disappearance of catatonia symptoms, and in view of the emergence of psychotic symptoms such as persecutory delusions, fearfulness, tablet risperidone 3 mg along with tablet trihexyphenidyl 2 mg was started. The patient showed improvement in symptoms as observed in follow-up. Catatonia is a complex neuropsychiatric syndrome characterized by psychomotor abnormalities such as mutism, negativism, posturing, and combativeness. It can be either independent or secondary to psychiatric conditions such as schizophrenia, mood disorders, neurologic, and systemic medical disorders.[3] The prevalence of catatonia in psychiatric settings ranges between 7% and 38%. A cross-cultural study reported the frequency of catatonia in India to be 13.5%.[4,5] As catatonia is a potentially fatal condition, timely intervention is of the utmost importance. Benzodiazepines, particularly lorazepam, are first-line agents in the management of catatonia due to their rapid onset and efficacy. Although there are no fixed regimens, usually lorazepam in the dose of 4-12mg either in the form of intravenous/intramuscular or a combination of intravenous or intramuscular and oral medication not exceeding 12mg/day is given.[6,7] Its mechanism involves potentiation of GABA-A receptors, enhancing chloride ion influx and leading to neuronal hyperpolarization. This produces anxiolytic, sedative, and muscle-relaxant effects.[8] However, lorazepam can cause hypotension, particularly in parenteral use or when administered at higher-than-recommended doses. When parenteral (IV) lorazepam is administered, due to its rapid onset of action, it can cause sudden central nervous system depression leading to reduced sympathetic flow from the brain, decreased systemic vascular resistance, and lowering cardiac output in some cases.[9] Furthermore, it causes peripheral vasodilation by inhibiting vascular muscle tone through central pathways, resulting in reduced venous return and preload, which further contribute to a fall in blood pressure. In this case, the initial 4 mg dose, administered intravenously to a lorazepam-naïve patient, likely triggered a profound vasodilatory response, compounded by possible autonomic dysregulation associated with catatonia. Although rare, benzodiazepine-induced hypotension has been reported, especially in patients receiving parenteral administration, older adults, or those with underlying cardiovascular vulnerability.[10,11] The case underscores the need for cautious dosing, especially when initiating treatment in patients with unclear drug sensitivity or in settings where immediate resuscitative support is not readily available. Notably, this patient’s deterioration occurred despite no co-administration of other sedatives, suggesting that lorazepam alone was the primary driver of hemodynamic compromise. The use of hydrocortisone and vasopressors (noradrenaline) proved essential in restoring hemodynamic stability. This case illustrates a rare but serious complication of lorazepam-induced hypotension in a patient with catatonia. Author contribution statement MS contributed to conceptualization, design, literature review, KA and CJA involved in manuscript writing and TSSR contributed to manuscript revision. Data availability statement Not applicable. Disclosure of use of AI assistive or generative devices The authors declare that authors have not used AI for writing the manuscript. Declaration of use of copyright tools Not applicable. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.