From the Guidelines
Tapering off benzodiazepines should always be done under medical supervision, with a recommended approach of a gradual dose reduction of 5-10% every 1-2 weeks, as seen in the EMPOWER trial 1. The goal is to minimize withdrawal symptoms and risks, and this approach has been shown to be effective in reducing the risk of rebound or withdrawal. For short-acting benzos like Xanax (alprazolam), patients may first be switched to equivalent doses of longer-acting medications like diazepam (Valium) or clonazepam (Klonopin), which have smoother withdrawal profiles. Some key points to consider when tapering off benzodiazepines include:
- Starting with a gradual dose reduction of 5-10% every 1-2 weeks, with slower reductions as the dose gets lower
- Switching to longer-acting medications like diazepam or clonazepam for smoother withdrawal profiles
- Monitoring for withdrawal symptoms like anxiety, insomnia, tremors, or sensory hypersensitivity
- Using complementary approaches like cognitive behavioral therapy, stress management techniques, and regular exercise to manage symptoms
- Allowing the brain's GABA receptors to gradually readjust to functioning without benzodiazepines, which prevents the severe withdrawal syndrome that can occur with abrupt discontinuation, as noted in a study on benzodiazepine withdrawal 1.
It's also important to note that the entire process may take months to a year or more, depending on the starting dose and duration of use, and that patients should be motivated and adherent to the tapering plan, as seen in a primary care approach to substance misuse 1. Additionally, some studies suggest that a reduction of the benzodiazepine dose by 25% every 1–2 weeks can be a safe and effective approach, as noted in a guideline for prescribing opioids for chronic pain 1. However, the most recent and highest quality study, the EMPOWER trial 1, recommends a more gradual approach, which should be prioritized in clinical practice.
Some benefits of this approach include:
- Reduced risk of rebound or withdrawal symptoms
- Improved management of anxiety and insomnia
- Increased success rates for tapering off benzodiazepines
- Enhanced patient safety and well-being, as noted in a study on evidence-based guidelines for mental, neurological, and substance use disorders 1.
Overall, tapering off benzodiazepines requires a careful and gradual approach, with close monitoring and support from medical professionals, as seen in a study on polypharmacy management in older patients 1.
From the FDA Drug Label
To reduce the risk of withdrawal reactions, use a gradual taper to discontinue clonazepam or reduce the dosage (a patient-specific plan should be used to taper the dose) Patients at an increased risk of withdrawal adverse reactions after benzodiazepine discontinuation or rapid dosage reduction include those who take higher dosages, and those who have had longer durations of use.
The recommended strategy for tapering off benzodiazepines, such as Xanax (alprazolam) or Klonopin (clonazepam), is to use a gradual taper to discontinue the medication or reduce the dosage. A patient-specific plan should be used to taper the dose. This approach is intended to minimize the risk of withdrawal reactions, which can be severe and even life-threatening. Patients who take higher dosages or have used benzodiazepines for longer durations are at increased risk of withdrawal adverse reactions and should be closely monitored during the tapering process 2 2.
From the Research
Tapering Off Benzodiazepines
Tapering off benzodiazepines, such as Xanax (alprazolam) or Klonopin (clonazepam), requires careful consideration of the patient's dosage and duration of use. The following strategies are recommended:
- For low-dose withdrawal, gradual tapering of the benzodiazepine over 4 weeks on an outpatient basis is suggested 3.
- For high-dose withdrawal, patients should be tolerance tested with diazepam and, if tolerant, tapered off medication as inpatients at a rate of 10% per day 3.
- Alprazolam should be titrated at a rate of 0.5 mg three times a day, regardless of whether the patient is being tapered for low- or high-dose withdrawal 3.
- A gradual taper of 25% per week reduction off benzodiazepine therapy may also be attempted, with the use of carbamazepine as an adjunctive therapy to reduce withdrawal severity 4.
Adjunctive Therapies
Adjunctive therapies, such as anticonvulsants, may be used to reduce withdrawal severity and improve outcomes. These include:
- Carbamazepine, which has been shown to be effective in reducing withdrawal severity and improving outcomes in patients discontinuing long-term benzodiazepine therapy 4.
- Valproic acid, gabapentin, clonazepam, and lamotrigine, which have been shown to be effective in treating neuropathic pain and may also be useful in benzodiazepine withdrawal 5.
- Gabapentin and pregabalin, which have been shown to be effective in treating social phobia (social anxiety disorder) and may also be useful in benzodiazepine withdrawal 6.
Special Considerations
Special considerations should be taken into account when tapering off benzodiazepines, including:
- The use of high-potency benzodiazepines, such as alprazolam and clonazepam, which may require special tapering schedules 3, 7.
- The risk of depression or panic, which may require antidepressant therapy 4.
- The importance of gradual tapering to minimize withdrawal symptoms and reduce the risk of relapse 3, 4.