From the FDA Drug Label
To reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage If a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level. Subsequently decrease the dosage more slowly
For alcohol withdrawal, a gradual taper of lorazepam is recommended to reduce the risk of withdrawal reactions.
- The taper schedule is not specified, but it is advised to decrease the dosage more slowly if withdrawal reactions occur.
- If a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous level, then decrease more slowly 1.
- The dosage of lorazepam should be individualized according to patient response.
From the Research
Diazepam is the preferred benzodiazepine for the treatment of moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life, which allows for a smoother withdrawal with less risk of breakthrough symptoms and rebound phenomena 2. When considering an Ativan taper for alcohol withdrawal, it's essential to note that while Ativan (lorazepam) is commonly used, the most recent and highest quality evidence suggests that diazepam may be a better option. A typical diazepam taper for alcohol withdrawal begins with a loading dose, followed by a gradual reduction over 3-7 days. The dose is then gradually reduced, decreasing by approximately 20-25% each day, with vital signs and withdrawal symptoms monitored regularly throughout the taper. Thiamine (100mg daily), folate, multivitamins, and adequate hydration are essential adjuncts to benzodiazepine therapy. This regimen works by enhancing GABA activity in the brain, which helps counteract the excessive neuronal excitability caused by alcohol cessation. Longer tapers may be needed for patients with severe withdrawal history, seizures, or delirium tremens. Fixed-dose regimens are generally preferred over symptom-triggered approaches in outpatient settings where continuous monitoring isn't possible. It's also worth noting that other studies have compared lorazepam to chlordiazepoxide, finding no significant difference in the development of delirium tremens, but lorazepam may require less adjuvant therapy to control symptoms 3. Additionally, carbamazepine has been studied as an alternative to benzodiazepines, but its role is still unclear, and benzodiazepines remain the primary treatment for moderate to severe alcohol withdrawal syndrome 4. In cases of severe alcohol withdrawal, protocolized administration of benzodiazepines, in combination with other agents, may be necessary to reduce the need for mechanical ventilation and lead to shorter ICU stays 5. Clonidine has also been investigated as a potential treatment for alcohol withdrawal, but its effectiveness is modest, and more data are needed to assess its potential in therapeutics 6.