How to transition from 2 mg Ativan (lorazepam) to Zoloft (sertraline)?

Transitioning from Lorazepam to Sertraline

The recommended approach for transitioning from 2 mg Ativan (lorazepam) to Zoloft (sertraline) is to gradually taper lorazepam while simultaneously starting sertraline, with complete discontinuation of lorazepam over 2-4 weeks to minimize withdrawal symptoms.

Understanding the Medication Switch

Lorazepam is a benzodiazepine anxiolytic used for short-term management of anxiety and insomnia, while sertraline is an SSRI antidepressant that is a first-line treatment for generalized anxiety disorder. This transition represents a shift from a short-acting benzodiazepine to a long-term anxiety treatment option.

Rationale for the Switch

• Lorazepam can lead to tolerance, addiction, depression, and cognitive impairment with regular use 1
• Approximately 10% of patients may experience paradoxical agitation with benzodiazepines 1
• SSRIs like sertraline are recommended first-line treatments for generalized anxiety disorder 2

Step-by-Step Transition Protocol

Week 1:

1. Start sertraline at 25-50 mg once daily in the morning
2. Continue lorazepam at current dose (2 mg) for the first 3-4 days
3. Reduce lorazepam to 1.5 mg daily (divided into 0.5 mg three times daily) for the remainder of week 1

Week 2:

1. Increase sertraline to 50-100 mg daily if tolerated
2. Reduce lorazepam to 1 mg daily (0.5 mg twice daily)

Week 3:

1. Maintain sertraline at effective dose
2. Further reduce lorazepam to 0.5 mg daily (at bedtime)

Week 4:

1. Continue sertraline at therapeutic dose
2. Discontinue lorazepam completely

Important Monitoring Considerations

Potential Withdrawal Symptoms

• Monitor for benzodiazepine withdrawal symptoms: insomnia, anxiety, irritability, tremor, headache, sensory hypersensitivity, and in severe cases, seizures 3
• Signs and symptoms of withdrawal from benzodiazepine therapy can be delayed 1

Sertraline Initiation Effects

• Common initial side effects include nausea, headache, dry mouth, insomnia, and diarrhea 4
• Full therapeutic effect of sertraline may take 4-6 weeks 2

Special Considerations

Cautions

• Never abruptly discontinue lorazepam after prolonged use due to risk of withdrawal symptoms 3
• The required time for weaning benzodiazepines is proportional to the duration of treatment 1
• If severe withdrawal symptoms occur, temporarily slow the taper schedule

Dosage Adjustments

• For elderly patients or those with hepatic impairment, use lower initial doses of sertraline (25 mg) and taper lorazepam more slowly 1
• If anxiety symptoms worsen significantly during transition, the lorazepam taper can be temporarily slowed

Alternative Approaches

If the standard approach is not tolerated:

1. Consider a slower lorazepam taper (10-20% reduction per week) 1
2. Divide lorazepam doses more frequently throughout the day during the taper
3. Adjust sertraline timing to evening if daytime sedation is problematic

Common Pitfalls to Avoid

• Tapering too quickly: This can lead to rebound anxiety and withdrawal symptoms
• Delaying sertraline initiation: Starting sertraline before complete lorazepam discontinuation helps maintain anxiety control
• Inadequate monitoring: Regular follow-up during the transition period is essential
• Overlooking drug interactions: While no major interactions exist between these medications, be aware of potential additive sedative effects during the overlap period

The transition from lorazepam to sertraline represents a shift from short-term symptomatic treatment to a more appropriate long-term anxiety management strategy, with the goal of improving morbidity, mortality, and quality of life by addressing the underlying anxiety disorder while avoiding benzodiazepine dependence.