What is a recommended taper schedule for a patient taking 2mg Ativan (lorazepam) four times a week?

Lorazepam Taper Schedule for 2mg Taken 4 Times Weekly

A gradual taper over 8-10 weeks is recommended for a patient taking 2mg of Ativan (lorazepam) four times weekly to minimize withdrawal symptoms and ensure patient safety.

Understanding the Current Situation

• Total weekly dose: 8mg (2mg × 4 times per week)
• Intermittent use pattern (not daily)
• FDA label specifically states: "To reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage" 1

Recommended Taper Schedule

Phase 1: Initial Reduction (Weeks 1-2)

• Reduce to 1.5mg per dose, maintaining 4 times weekly
• Weekly dose: 6mg (25% reduction from original)

Phase 2: Gradual Reduction (Weeks 3-4)

• Reduce to 1mg per dose, maintaining 4 times weekly
• Weekly dose: 4mg (50% reduction from original)

Phase 3: Continued Reduction (Weeks 5-6)

• Reduce to 0.5mg per dose, maintaining 4 times weekly
• Weekly dose: 2mg (75% reduction from original)

Phase 4: Final Tapering (Weeks 7-8)

• Reduce to 0.25mg per dose, maintaining 4 times weekly
• Weekly dose: 1mg (87.5% reduction from original)

Phase 5: Discontinuation (Weeks 9-10)

• Reduce to 0.25mg per dose, 2 times weekly for 1-2 weeks
• Then discontinue completely

Rationale and Evidence

This tapering schedule aligns with the FDA guidance for lorazepam, which emphasizes gradual dose reduction to minimize withdrawal symptoms 1. The schedule follows the principle of reducing by approximately 10-20% every 1-2 weeks, which is consistent with evidence-based approaches for benzodiazepine tapering.

The FDA label specifically warns: "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" 1.

Monitoring During Taper

Monitor for withdrawal symptoms including:

• Anxiety, irritability, insomnia
• Tremors, headaches, muscle aches
• Nausea, sweating, palpitations
• Sensory hypersensitivity

Important Considerations

1. Withdrawal Risk: Signs and symptoms of withdrawal from benzodiazepine therapy can be delayed 2. Even with intermittent use (4 times weekly), physical dependence can develop.

2. Individualized Adjustments: If withdrawal symptoms become severe, pause the taper at the current dose for an additional 1-2 weeks before continuing.

3. Adjunctive Support: Consider non-pharmacological approaches to manage anxiety during the taper:

   • Cognitive behavioral therapy
   • Relaxation techniques
   • Sleep hygiene practices

4. Potential Pitfalls:

   • Tapering too quickly increases risk of withdrawal symptoms
   • Benzodiazepine withdrawal can potentially be dangerous (seizures in severe cases)
   • Avoid abrupt discontinuation which can lead to severe withdrawal

5. Liquid Formulation Option: For the smallest doses in the final phases, consider using a liquid formulation if available, as it allows for more precise dosing 3.

This schedule provides a structured approach to safely discontinue lorazepam while minimizing withdrawal symptoms and maintaining patient safety. The gradual reduction over 8-10 weeks allows the body to adjust to decreasing benzodiazepine levels, reducing the risk of withdrawal complications.