What is the suggested tapering regimen for lorazepam (Ativan) 2 milligrams nightly?

From the Guidelines

I strongly recommend a gradual taper of lorazepam 2 mg nightly, reducing the dose by 25% every 1-2 weeks, to minimize withdrawal symptoms and ensure patient safety, as suggested by the contextual evidence review 1. To initiate the taper, start by reducing the dose to 1.5 mg nightly for 1-2 weeks, then decrease to 1 mg nightly for another 1-2 weeks, followed by 0.5 mg nightly for 1-2 weeks, and finally 0.5 mg every other night for 1 week before stopping completely. This approach is supported by a commonly used tapering schedule that has been used safely and with moderate success, as mentioned in the study 1. Some key points to consider during the taper include:

• Maintaining good sleep hygiene by establishing a regular sleep schedule, avoiding caffeine and alcohol, and creating a relaxing bedtime routine
• Monitoring for rebound anxiety, insomnia, irritability, or restlessness, and slowing down the taper if symptoms become severe
• Considering cognitive behavioral therapy (CBT) to increase tapering success rates, especially for patients struggling with the benzodiazepine taper 1
• Collaborating with the patient on the tapering plan and following up frequently to support the patient during the ongoing taper process, as recommended in the 2022 CDC clinical practice guideline for prescribing opioids for pain 1. It's essential to prioritize patient safety and well-being during the tapering process, and a gradual taper of lorazepam 2 mg nightly is the most appropriate approach to minimize withdrawal symptoms and ensure a successful taper, as supported by the highest quality evidence available 1.

From the Research

Lorazepam Tapering

• The suggested lorazepam 2 mg nightly taper is a common dosage for managing anxiety and sleep disorders, as seen in the study 2 where lorazepam was evaluated in a 2-mg dose.
• However, it's essential to consider the potential for rebound insomnia and withdrawal symptoms when tapering off lorazepam, as noted in the study 2 where significant worsening of sleep and increases in tension and anxiety were observed after drug withdrawal.
• Benzodiazepines, including lorazepam, have a high potential for dependence and addiction, making careful tapering crucial to avoid severe withdrawal symptoms 3.

Tapering Considerations

• The study 3 highlights the importance of careful tapering when discontinuing benzodiazepines, suggesting that clonazepam may be used for tapering.
• However, the optimal tapering schedule for lorazepam is not well-established, and more research is needed to determine the best approach 3.
• The study 4 suggests that a 2 mg dose of lorazepam may be an optimal dose for certain clinical applications, but its relevance to tapering is unclear.

Alternative Treatments

• Other studies have explored the efficacy of benzodiazepines compared to other treatments, such as serotonergic antidepressants, for anxiety disorders 5.
• The study 5 found that benzodiazepines were more effective than serotonergic antidepressants for generalized anxiety disorder, but the relevance of this finding to lorazepam tapering is unclear.
• The study 6 discusses the pharmacology of benzodiazepines and their interactions with various receptors, which may be relevant to understanding the mechanisms of lorazepam tapering.