What is a recommended tapering schedule for a patient taking Ativan (lorazepam) 2 mg?

Lorazepam (Ativan) 2 mg Tapering Schedule

The recommended tapering schedule for a patient taking Ativan (lorazepam) 2 mg is to reduce the dose by 0.5 mg every 2 weeks, followed by a reduction to 0.25-0.5 mg for elderly or debilitated patients, with a maximum of 2 mg in 24 hours. 1

Initial Assessment and Planning

Before beginning the taper:

• Assess duration of use (short-term: <1 year; long-term: ≥1 year)
• Evaluate risk factors for difficult withdrawal (elderly status, history of seizures, concurrent medications)
• Discuss the tapering plan with the patient, explaining potential withdrawal symptoms

Tapering Protocol for Lorazepam 2 mg

Standard Tapering Schedule

1. Weeks 1-2: Reduce from 2 mg to 1.5 mg daily
2. Weeks 3-4: Reduce from 1.5 mg to 1 mg daily
3. Weeks 5-6: Reduce from 1 mg to 0.5 mg daily
4. Weeks 7-8: Reduce from 0.5 mg to 0.25 mg daily
5. Weeks 9-10: Discontinue completely

This follows the FDA recommendation for a gradual taper to minimize withdrawal symptoms 1. For elderly or debilitated patients, consider starting at a lower dose (1-2 mg/day) and tapering more slowly 1.

Alternative Slower Tapering Schedule (for long-term users)

For patients who have been on lorazepam for more than a year, consider a slower taper:

1. Month 1: Reduce from 2 mg to 1.75 mg daily
2. Month 2: Reduce from 1.75 mg to 1.5 mg daily
3. Month 3: Reduce from 1.5 mg to 1.25 mg daily
4. Month 4: Reduce from 1.25 mg to 1 mg daily
5. Month 5: Reduce from 1 mg to 0.75 mg daily
6. Month 6: Reduce from 0.75 mg to 0.5 mg daily
7. Month 7: Reduce from 0.5 mg to 0.25 mg daily
8. Month 8: Discontinue completely

Managing Withdrawal Symptoms

Common withdrawal symptoms include:

• Anxiety and agitation
• Insomnia
• Tremors
• Headache
• Nausea/vomiting
• Sweating
• Tachycardia/palpitations

If withdrawal symptoms become severe during tapering:

1. Pause the taper at the current dose until symptoms resolve 1
2. Resume tapering at a slower rate (e.g., 5% reduction instead of 10%) 2
3. Consider symptom management with non-benzodiazepine medications:
   • Hydroxyzine for anxiety and agitation
   • Trazodone for insomnia
   • Clonidine for sympathetic hyperactivity
   • Acetaminophen for pain (not exceeding 3000mg daily) 2

Special Considerations

• Concurrent medications: If the patient is also taking opioids, prescribe the lowest effective dosage of lorazepam and monitor closely for respiratory depression 1
• Elderly patients: Use a slower tapering schedule with 5% reductions and more frequent monitoring 2
• History of seizures: Consider even slower tapering and consultation with neurology
• Pregnancy: Consult appropriate expertise before tapering due to risks to both mother and fetus 2

Follow-up and Monitoring

• Schedule regular follow-up appointments at least monthly during the tapering process
• Monitor for withdrawal symptoms at each visit
• Assess for the need for adjunctive treatments to manage withdrawal symptoms
• If withdrawal symptoms become severe, pause the taper temporarily and resume at a slower rate 2

Non-Pharmacological Support

Recommend the following supportive measures during tapering:

• Cognitive behavioral therapy
• Regular exercise
• Sleep hygiene practices
• Stress management techniques
• Support groups

By following this structured tapering schedule and providing appropriate support, most patients can successfully discontinue lorazepam while minimizing withdrawal symptoms.