What is a recommended weaning schedule for a patient taking 2mg of Ativan (lorazepam) twice a week, using a 10% reduction?

Lorazepam Weaning Schedule for 2mg Twice Weekly

For a patient taking 2mg of Ativan (lorazepam) twice weekly, I recommend implementing a 10% reduction every 1-2 weeks, starting with a reduction to 1.8mg twice weekly, then continuing with gradual decrements until discontinuation.

Understanding the Patient's Situation

The patient is currently taking a relatively infrequent dosing schedule (2mg twice weekly), which presents a unique tapering situation compared to daily use. This intermittent dosing pattern suggests:

• Possible use for specific situational anxiety
• Lower risk of severe withdrawal compared to daily use
• Still requires careful tapering to minimize withdrawal symptoms

Recommended Tapering Protocol

Initial Assessment

• Determine duration of lorazepam use (if >14 days, slower taper needed)
• Assess for any history of withdrawal symptoms
• Evaluate for underlying anxiety disorders that may need alternative treatment

Specific Weaning Schedule

1. Weeks 1-2: Reduce by 10% to 1.8mg twice weekly
2. Weeks 3-4: Reduce to 1.6mg twice weekly
3. Weeks 5-6: Reduce to 1.4mg twice weekly
4. Weeks 7-8: Reduce to 1.2mg twice weekly
5. Weeks 9-10: Reduce to 1.0mg twice weekly
6. Weeks 11-12: Reduce to 0.8mg twice weekly
7. Weeks 13-14: Reduce to 0.6mg twice weekly
8. Weeks 15-16: Reduce to 0.4mg twice weekly
9. Weeks 17-18: Reduce to 0.2mg twice weekly
10. Week 19: Discontinue

Rationale for This Approach

The FDA label for lorazepam recommends "a gradual taper to discontinue lorazepam or reduce the dosage" to minimize withdrawal reactions 1. While the label doesn't specify exact percentages, clinical guidelines support a 10-20% reduction approach for benzodiazepines 2.

Monitoring During Tapering

Withdrawal Symptoms to Monitor

• Anxiety, irritability, insomnia
• Tremors, headache
• Sensory hypersensitivity
• Nausea, vomiting
• Muscle stiffness or pain
• Seizures (rare but serious)

Adjustments to Schedule

• If withdrawal symptoms occur, pause the taper and maintain current dose until symptoms resolve
• Once stable, resume tapering at a slower rate (5% reductions instead of 10%)
• If severe symptoms occur, consider temporarily returning to the previous dose 1

Important Clinical Considerations

Potential Pitfalls

• Too rapid tapering: Even with twice-weekly dosing, abrupt discontinuation can trigger withdrawal symptoms
• Inflexible schedule: Failure to adjust based on patient response can lead to withdrawal or treatment failure
• Overlooking psychological dependence: The anticipatory anxiety about not having medication available can be significant

Special Considerations

• For elderly patients, consider an even more gradual taper with 5% reductions 2
• If the patient has liver impairment, slower tapering may be necessary due to altered metabolism
• Consider adjunctive treatments for managing withdrawal symptoms (e.g., relaxation techniques, sleep hygiene)

Evidence-Based Rationale

The recommended 10% reduction approach is supported by guidelines for benzodiazepine weaning. While most evidence focuses on daily benzodiazepine use, the principles of gradual tapering still apply to intermittent dosing 2. The pediatric literature suggests that 10-20% reductions are generally well-tolerated 3, and this approach can be applied to adults with appropriate monitoring.

The schedule allows for adjustment based on individual response, which is critical since "individual patient response to weaning is more important than following a rigid schedule" 2.