How to safely taper a patient off long-term benzodiazepines (Benzodiazepines)?

From the Guidelines

Tapering a patient off long-term benzodiazepines requires a gradual, individualized approach to minimize withdrawal symptoms, with a recommended reduction of the benzodiazepine dose by 10-25% every 1-2 weeks, slowing the taper as the dose decreases, as suggested by the most recent and highest quality study 1.

Key Considerations

• The tapering process should be individualized, taking into account the patient's specific needs and circumstances.
• A commonly used tapering schedule involves reducing the benzodiazepine dose by 10-25% every 1-2 weeks, with slower tapering needed if significant withdrawal symptoms occur.
• Adjunctive treatments like cognitive behavioral therapy, relaxation techniques, and sometimes medications like propranolol for physical symptoms or trazodone for sleep can help manage withdrawal symptoms.
• The entire process often takes 3-6 months but may require up to 12 months for patients on very high doses or with long-term use.

Tapering Schedule

• Begin by converting the patient's current benzodiazepine to an equivalent dose of a long-acting benzodiazepine like diazepam.
• Reduce the dose by 10-25% every 1-2 weeks, slowing the taper as the dose decreases.
• For instance, start with a 20% reduction, then decrease to 10% reductions as the dose gets lower.
• A typical schedule might involve reducing from 40mg to 30mg, then to 25mg, 20mg, 15mg, 10mg, 7.5mg, 5mg, 2.5mg, and finally to zero over several months.

Monitoring and Adjustments

• Monitor patients closely for withdrawal symptoms such as anxiety, insomnia, irritability, or seizures, and adjust the tapering schedule accordingly.
• Slower tapering is needed if significant withdrawal symptoms occur.
• Clinicians should collaborate with the patient on the tapering plan, including patients in decisions such as how quickly tapering will occur and when pauses in the taper might be warranted, as recommended by 1.

Additional Recommendations

• Patient agreement and interest in tapering is likely to be a key component of successful tapers, as suggested by 1.
• Clinicians should access appropriate expertise if considering tapering opioids during pregnancy because of possible risks to the pregnant patient and the fetus if the patient goes into withdrawal, as recommended by 1.
• Clinicians should remain alert to signs of and screen for anxiety, depression, and opioid misuse or opioid use disorder that might be revealed by an opioid taper and provide treatment or arrange for management of these comorbidities, as recommended by 1.

From the FDA Drug Label

Withdrawal reactions may occur when dosage reduction occurs for any reason. This includes purposeful tapering, but also inadvertent reduction of dose (e.g., the patient forgets, the patient is admitted to a hospital). Therefore, the dosage of alprazolam tablets should be reduced or discontinued gradually (see DOSAGE AND ADMINISTRATION)

While it is difficult to distinguish withdrawal and recurrence for certain patients, the time course and the nature of the symptoms may be helpful A withdrawal syndrome typically includes the occurrence of new symptoms, tends to appear toward the end of taper or shortly after discontinuation, and will decrease with time.

Patients, especially individuals with a history of seizures or epilepsy, should not be abruptly discontinued from any CNS depressant agent, including alprazolam tablets It is recommended that all patients on alprazolam tablets who require a dosage reduction be gradually tapered under close supervision (see WARNINGS and DOSAGE AND ADMINISTRATION)

To safely taper a patient off long-term benzodiazepines, such as alprazolam, it is essential to:

• Gradually reduce the dosage to minimize the risk of withdrawal reactions, including seizures
• Taper under close supervision to monitor for signs and symptoms of withdrawal
• Avoid abrupt discontinuation, especially in patients with a history of seizures or epilepsy
• Follow a recommended tapering schedule, as outlined in the DOSAGE AND ADMINISTRATION section of the drug label 2 2
• Be aware that psychological dependence is a risk with all benzodiazepines, including alprazolam, and that addiction-prone individuals should be under careful surveillance when receiving alprazolam tablets. Key considerations include:
• Dose and duration of treatment: The risk of withdrawal phenomena appears to be related to dose and duration of treatment
• Time course and nature of symptoms: A withdrawal syndrome typically includes the occurrence of new symptoms, tends to appear toward the end of taper or shortly after discontinuation, and will decrease with time
• Close supervision: Patients requiring a dosage reduction should be gradually tapered under close supervision to monitor for signs and symptoms of withdrawal.

From the Research

Safely Tapering Off Long-Term Benzodiazepines

To safely taper a patient off long-term benzodiazepines, several strategies can be employed:

• Gradual tapering over a period of weeks or months, with frequent follow-up to evaluate for signs of withdrawal or the return of symptoms 3
• Using cognitive behavioral therapy (CBT) in conjunction with gradual tapering, which has been shown to increase abstinence success to 70-80% 4
• Implementing psychotherapy or other nonpharmacological modalities in the management of anxiety or insomnia 3
• Prescribing limited quantities of a drug with a short elimination half-life, with a return visit for re-evaluation of effectiveness and adverse effects 3

Factors to Consider

When tapering off long-term benzodiazepines, several factors should be considered:

• Personality factors, such as high Eysenck neuroticism, female sex, and mild-to-moderate alcohol use, which can contribute to withdrawal severity 5
• Baseline personality, which can affect the patient's difficulties with gradual benzodiazepine discontinuation 5
• The daily benzodiazepine dose or benzodiazepine half-life, which may not be as significant in predicting withdrawal severity as previously thought 5

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) has been shown to be an effective treatment option for discontinuing benzodiazepines in patients with anxiety disorders:

• CBT can be used in conjunction with gradual tapering to increase abstinence success 6
• CBT can be used as a monotherapy, with dropout rates similar to or lower than those patients undergoing other forms of therapy, including benzodiazepines 7
• CBT can be used as a bridge between benzodiazepine use and discontinuation during a medication taper, to avoid loss of efficacy 7