What is the recommended tapering regimen for a patient on Xanax (alprazolam) to a long-acting benzodiazepine?

Alprazolam to Long-Acting Benzodiazepine Tapering Protocol

The recommended tapering regimen for patients on Xanax (alprazolam) involves converting to a long-acting benzodiazepine such as clonazepam, followed by a gradual taper of 10% per month to minimize withdrawal symptoms and prevent serious complications like seizures.

Conversion Process

1. Calculate equivalent dose:

   • Determine the total daily alprazolam dose
   • Convert to equivalent dose of a long-acting benzodiazepine:
     • Clonazepam is preferred (1mg alprazolam ≈ 2mg clonazepam)
     • Diazepam is an alternative (1mg alprazolam ≈ 10mg diazepam)

2. Initial stabilization:

   • Divide the long-acting benzodiazepine into 2-4 doses per day
   • Stabilize on this dose for 1-2 weeks before beginning taper

Tapering Schedule

Standard Approach

• Reduce dose by 10% per month for long-term users 1
• For patients on higher doses (>4mg/day alprazolam equivalent), expect a more difficult taper 2
• Total tapering duration typically ranges from 3-6 months for most patients, but may take longer for those on high doses or with long-term use 1

Specific Tapering Strategy

1. Initial phase (first month):

   • Reduce dose by 10% of original dose
   • Monitor for withdrawal symptoms weekly

2. Middle phase:

   • Continue 10% reductions monthly
   • If withdrawal symptoms emerge, return to previous dose and slow the taper

3. Final phase:

   • When reaching approximately 25% of the original dose, slow the taper further
   • Consider reducing by 5% increments

Managing Withdrawal Symptoms

• Common withdrawal symptoms: heightened sensory perception, impaired concentration, paresthesias, muscle cramps, diarrhea, blurred vision, anxiety, insomnia 2

• Severe withdrawal symptoms: seizures (most common 24-72 hours after discontinuation) 2

• If withdrawal symptoms emerge:

  • Return to previous tolerated dose
  • Resume tapering at a slower rate
  • Consider temporary symptomatic management

Special Considerations

• High-dose users: Patients taking >4mg/day of alprazolam have more difficulty tapering to zero dose 2
• Duration of use: Longer duration of use may require more gradual tapering
• Seizure history: Increased risk of withdrawal seizures, especially with abrupt discontinuation 3
• Elderly patients: More sensitive to benzodiazepine effects, may require more gradual tapering 1

Monitoring and Support

• Weekly contact during active tapering to assess:
  • Withdrawal symptoms
  • Emergence of new side effects
  • Changes in mood, anxiety, or suicidal ideation
  • Medication adherence to the tapering schedule 1

Potential Pitfalls

• Abrupt discontinuation: Can lead to severe withdrawal symptoms including seizures 2, 3
• Tapering too quickly: May result in rebound anxiety and withdrawal symptoms
• Interdose withdrawal: Early morning anxiety or symptoms between doses may require more frequent dosing 2
• Psychological dependence: More common with higher doses (>4mg/day) and longer-term use 2

By following this structured approach to tapering alprazolam to a long-acting benzodiazepine, the risk of withdrawal symptoms and complications can be minimized while successfully discontinuing the medication.