What is the recommended taper plan for a patient taking 2mg of Ativan (lorazepam) four times a week, aiming for a 5% reduction per week?

Lorazepam Tapering Plan for Patient Taking 2mg Four Times Weekly

A 5% weekly reduction tapering schedule is an appropriate approach for discontinuing lorazepam to minimize withdrawal symptoms. For a patient taking 2mg of lorazepam four times weekly (8mg total weekly dose), I recommend implementing a hyperbolic taper with approximately 5-10% reductions from the most recent dose every 1-2 weeks, with smaller reductions as the dose decreases. 1

Initial Assessment and Preparation

Before beginning the taper:

• Confirm the current usage pattern (2mg four times weekly = 8mg total weekly dose)
• Assess for any history of previous withdrawal symptoms
• Evaluate for any comorbid conditions that may complicate tapering

Detailed Tapering Schedule

Phase 1: Initial Reduction (Weeks 1-4)

• Week 1: Reduce by 5% to 1.9mg four times weekly (7.6mg total)
• Week 2: Reduce to 1.8mg four times weekly (7.2mg total)
• Week 3: Reduce to 1.7mg four times weekly (6.8mg total)
• Week 4: Reduce to 1.6mg four times weekly (6.4mg total)

Phase 2: Mid-Taper (Weeks 5-12)

• Week 5-6: Reduce to 1.5mg four times weekly (6mg total)
• Week 7-8: Reduce to 1.4mg four times weekly (5.6mg total)
• Week 9-10: Reduce to 1.3mg four times weekly (5.2mg total)
• Week 11-12: Reduce to 1.2mg four times weekly (4.8mg total)

Phase 3: Lower Dose Reductions (Weeks 13-24)

• Week 13-14: Reduce to 1.1mg four times weekly (4.4mg total)
• Week 15-16: Reduce to 1mg four times weekly (4mg total)
• Week 17-18: Reduce to 0.9mg four times weekly (3.6mg total)
• Week 19-20: Reduce to 0.8mg four times weekly (3.2mg total)
• Week 21-22: Reduce to 0.7mg four times weekly (2.8mg total)
• Week 23-24: Reduce to 0.6mg four times weekly (2.4mg total)

Phase 4: Final Reductions (Weeks 25-40)

• Week 25-26: Reduce to 0.5mg four times weekly (2mg total)
• Week 27-28: Reduce to 0.4mg four times weekly (1.6mg total)
• Week 29-30: Reduce to 0.3mg four times weekly (1.2mg total)
• Week 31-33: Reduce to 0.25mg four times weekly (1mg total)
• Week 34-36: Reduce to 0.2mg four times weekly (0.8mg total)
• Week 37-38: Reduce to 0.125mg four times weekly (0.5mg total)
• Week 39-40: Reduce to 0.06mg four times weekly (0.24mg total)
• Week 41: Discontinue

Implementation Notes

1. Dose Preparation: For doses below 0.5mg, liquid lorazepam concentrate may be used with a calibrated dropper for precise measurement 2

2. Hyperbolic Tapering Rationale: This method reduces the biological effect at receptors by fixed amounts to minimize withdrawal symptoms 3, 4

3. Slower Reductions at Lower Doses: As the dose decreases, the percentage of receptor occupancy changes more dramatically with each reduction, necessitating smaller absolute reductions 4, 5

4. Monitoring for Withdrawal Symptoms: Common symptoms include anxiety, trembling, insomnia, sweating, tachycardia, headache, and muscle aches 6

Adjunctive Treatments for Withdrawal Symptoms

If withdrawal symptoms emerge, consider:

• For anxiety/irritability: Temporarily pause the taper or return to previous dose before proceeding more slowly 2
• For insomnia: Consider short-term use of trazodone 1
• For physical symptoms: α2-agonists like clonidine may help with autonomic symptoms 1

Important Caveats and Considerations

• This schedule may need to be adjusted based on individual response. If withdrawal symptoms emerge, slow the taper further.
• The FDA specifically warns against abrupt discontinuation of benzodiazepines due to risk of withdrawal reactions 2
• Evidence suggests that slower tapers (over months rather than weeks) are more successful in reducing withdrawal symptoms 3
• The final stages of tapering may require very small doses (as low as 1/40th of the therapeutic dose) to prevent significant changes in receptor occupancy 4
• If symptoms become intolerable, temporarily pausing the taper or returning to the previous dose before proceeding more slowly is recommended 2

This tapering plan follows evidence-based approaches to minimize withdrawal symptoms while safely discontinuing lorazepam, with the goal of reducing morbidity and maintaining quality of life throughout the discontinuation process.