Lorazepam Tapering Plan for Intermittent Use (2mg Three Times Weekly)
For a patient taking 2mg of Ativan (lorazepam) three times a week, I recommend a gradual taper over 8-12 weeks, reducing by approximately 25% of the most recent dose every 1-2 weeks to minimize withdrawal symptoms and prevent relapse.
Understanding the Current Situation
The patient is taking lorazepam 2mg three times weekly, which is:
- An intermittent dosing schedule (not daily)
- A moderate dose per administration
- A benzodiazepine with potential for dependence even with intermittent use
Recommended Tapering Schedule
Initial Phase (Weeks 1-4)
- Weeks 1-2: Reduce to 1.5mg three times weekly (25% reduction)
- Weeks 3-4: Reduce to 1mg three times weekly (33% reduction from previous dose)
Middle Phase (Weeks 5-8)
- Weeks 5-6: Reduce to 0.5mg three times weekly (50% reduction from previous dose)
- Weeks 7-8: Reduce to 0.5mg twice weekly (reduce frequency)
Final Phase (Weeks 9-12)
- Weeks 9-10: Reduce to 0.25mg twice weekly (50% reduction from previous dose)
- Weeks 11-12: Reduce to 0.25mg once weekly, then discontinue
Rationale for This Approach
The FDA drug label for lorazepam recommends "a gradual taper to discontinue lorazepam or reduce the dosage" to minimize withdrawal reactions 1. While the FDA doesn't specify exact percentages for intermittent use, the recommended approach follows established principles for benzodiazepine tapering.
This schedule is supported by evidence showing that gradual tapering of benzodiazepines is more successful than rapid discontinuation. A study on clonazepam tapering found that reducing by 0.25mg per week after reaching 1mg daily was effective with minimal withdrawal symptoms 2.
Monitoring During Tapering
Monitor for withdrawal symptoms including:
- Anxiety, restlessness, irritability
- Insomnia or nightmares
- Tremors or shaking
- Nausea/vomiting
- Excessive sweating
- Tachycardia/palpitations
- Headache or muscle aches
Adjustments to the Taper
If withdrawal symptoms become problematic:
- Pause the taper at the current dose for an additional 1-2 weeks
- Resume tapering once symptoms stabilize
- Consider slowing the taper to 10% reductions if needed
Important Considerations
Avoid concurrent use with other CNS depressants: The CDC guidelines highlight that concurrent use of benzodiazepines with opioids or other CNS depressants significantly increases overdose risk 3.
Individualized adjustments: The Mayo Clinic Proceedings notes that "finding a plan that an individual patient can embrace with a significant degree of personal engagement might be more important than following a specific protocol" 3.
Adjunctive medications: If withdrawal symptoms are problematic, consider short-term use of adjunctive medications:
- α2-agonists like clonidine may help attenuate withdrawal symptoms 3
- Non-benzodiazepine sleep aids may temporarily help with insomnia
Special consideration: Since the patient is only taking lorazepam three times weekly (not daily), physical dependence may be less severe than with daily use, potentially allowing for a slightly faster taper than would be recommended for daily users.
Pitfalls to Avoid
Abrupt discontinuation: This can precipitate severe withdrawal symptoms including rebound anxiety, insomnia, and in rare cases, seizures.
Tapering too quickly: The CDC notes that "patients tapering opioids after taking them for years might require very slow opioid tapers" 3, and the same principle applies to benzodiazepines.
Mistaking withdrawal for recurrence: Withdrawal symptoms can mimic the original symptoms for which the medication was prescribed.
Neglecting psychological support: Providing reassurance and education about the tapering process is essential for success.
By following this gradual, structured approach, the patient has the best chance of successfully discontinuing lorazepam while minimizing withdrawal symptoms and maintaining quality of life.