From the Guidelines
Having PRN (as needed) Ativan (lorazepam) in addition to a taper is generally not recommended. A proper benzodiazepine taper should be structured to gradually reduce dependence while managing withdrawal symptoms, making additional as-needed doses counterproductive. The taper schedule itself should be designed to minimize withdrawal symptoms by slowly decreasing the dose over time, typically reducing by 5-10% every 1-2 weeks depending on individual response, as suggested by the CDC guideline for prescribing opioids for chronic pain 1. Adding PRN doses during a taper can interfere with this process by creating inconsistent blood levels, potentially reinforcing psychological dependence, and making it difficult to track progress.
Instead, if withdrawal symptoms become problematic during a taper, it's better to temporarily pause the taper at the current dose until symptoms stabilize, or slow the rate of reduction, rather than adding PRN doses. This approach maintains the downward trajectory while still providing symptom control. Any adjustments to a benzodiazepine taper should always be discussed with the prescribing healthcare provider, as individual circumstances may vary. The CDC guideline also emphasizes the importance of avoiding concurrent use of opioids and benzodiazepines whenever possible due to the increased risk of fatal overdose 1.
Some key points to consider when tapering benzodiazepines include:
- Gradually reducing the dose by 25% every 1–2 weeks, as suggested by the CDC guideline 1
- Using evidence-based psychotherapies, such as cognitive-behavioral therapy (CBT), to increase tapering success rates 1
- Offering alternative treatments for anxiety, such as specific anti-depressants or other nonbenzodiazepine medications approved for anxiety, if benzodiazepines are tapered or discontinued 1
- Communicating with mental health professionals managing the patient to discuss the patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care 1.
It's also important to note that the determination to taper or discontinue opioids or benzodiazepines should be based on individual patient needs and circumstances, taking into account the potential benefits and risks of treatment, as emphasized by the consensus panel recommendations for ensuring patient protections when tapering opioids 1.
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.
The FDA drug label does not answer the question of whether to have prn Ativan in addition to a taper.
From the Research
Benzodiazepine Taper and PRN Ativan
- The use of benzodiazepines, such as Ativan, is a common practice in managing anxiety and insomnia, but it comes with the risk of dependence and withdrawal symptoms 2.
- When tapering off benzodiazepines, it is crucial to do so carefully to avoid severe withdrawal symptoms, which can be life-threatening 2.
- There is no direct evidence to suggest that having PRN (as-needed) Ativan in addition to a taper is beneficial or recommended 2, 3, 4, 5, 6.
- Alternative therapies, such as cognitive behavioral therapy for insomnia (CBT-i), have been shown to be effective in managing insomnia and anxiety without the risk of dependence or withdrawal symptoms 3.
- Non-pharmacological approaches, such as sleep restriction-sleep compression therapy and cognitive behavioral therapy for anxiety or insomnia, are also proposed as alternatives for treating insomnia and anxiety in older adults 6.
Considerations for Benzodiazepine Use
- Benzodiazepines are commonly prescribed for their anxiolytic, sedative, and anticonvulsant properties, but their use is associated with risks, including dependence, tolerance, and potential for addiction and misuse 2, 4.
- The efficacy of benzodiazepines in treating generalized anxiety disorder presenting with high levels of insomnia has been assessed, and alternative therapies, such as pregabalin, have been shown to be effective in improving overall anxiety symptoms and insomnia 5.
- The American Geriatrics Society advises against using benzodiazepines or nonbenzodiazepine hypnotics in older adults due to the high risk of serious adverse effects 6.