Benzodiazepine Tapering

One common issue on consult service is patients taking chronic benzodiazepines. A few practical principles are helpful when thinking about tapering.

1️⃣ Short-Term Use 

Patients on a benzodiazepine (except alprazolam) for:

• < 1 month
• At manufacturer-recommended doses
  • Example: Lorazepam 2–6 mg/day

Usually do not require a taper.

2️⃣ Longer-Term Use at Standard Doses

Patients on a benzodiazepine (except alprazolam) for:

• > 1 month
• At manufacturer-recommended doses

➡️ Can typically be tapered over ~4 weeks as an outpatient. Reduce by 25% q2week, may slow down to 12.5% q2weeks closer to stopping if needed.

If Inpatient, can reduce by up to 10mg diazepam equivalents per day with CIWA monitoring

However:

• Some patients may require much slower tapers
• tapering may be months to 1+ year

3️⃣ Very High-Dose 

Approximately ≥ 100 mg diazepam equivalents per day

If taken for several months, these patients are:

• At highest risk for severe withdrawal
• At risk for seizures, delirium, autonomic instability

Inpatient management is recommended

Approach:

1. Convert to a long-acting benzodiazepine (e.g., diazepam)
   1. Rationale:
   2. Smoother taper
   3. Less rebound anxiety
   4. Less severe withdrawal
   5. Lower dropout rates
2. Taper the long-acting agent by approximately 10% per day inpatient
3. Monitor closely for withdrawal symptoms and seizures

***Special Note: Alprazolam 

Alprazolam is different because:

• Short half-life
• Higher rebound anxiety
• Less predictable cross-coverage when switching to long-acting agents

If patients do not tolerate conversion to a long-acting benzodiazepine: You may need to switch back to alprazolam and taper directly.