How do I taper lorazepam (Ativan) safely?

Safely Tapering Lorazepam (Ativan)

To safely taper lorazepam, reduce the dose by 10% of the original dose per week as a starting point, with slower tapers (10% per month) often better tolerated for long-term users. 1, 2

Tapering Protocol for Lorazepam

Initial Assessment

• Determine total daily dose currently being taken
• Evaluate duration of use (longer use requires slower tapering)
• Assess for risk factors: advanced age, liver disease, respiratory issues, history of seizures, concurrent opioid or alcohol use

Recommended Tapering Schedule

1. Standard Taper Rate:

   • Reduce dose by 10% of original dose per week 1
   • Example: If taking 2mg/day, reduce by 0.2mg per week

2. For Long-Term Users (months/years):

   • Slower taper of 10% per month is better tolerated 3
   • May require 3-6 months for complete discontinuation

3. For High-Risk Situations (severe adverse events):

   • More rapid taper over 2-3 weeks may be necessary 1

Practical Implementation

• Divide total daily dose into multiple doses (e.g., every 6 hours) to maintain stable blood levels 3
• When reaching the smallest available dose, extend the interval between doses 1
• Stop medication when taking less frequently than once daily 1

Managing Withdrawal Symptoms

Common Withdrawal Symptoms

• Anxiety, insomnia, tremor
• Nausea, vomiting, abdominal pain
• Diaphoresis (excessive sweating)
• Tachycardia, hypertension
• Headache, muscle aches
• Drug craving 1

Withdrawal Management Strategies

• If withdrawal symptoms emerge, return to previous dose and resume tapering at a slower rate 3
• Temporary symptomatic management may include:
  • GABA agonists (pregabalin, gabapentin) for severe symptoms 3
  • Anticonvulsants (carbamazepine, valproate) to reduce seizure risk 3
  • Thiamine supplementation (100-300 mg/day) if there's history of alcohol use 1

Special Populations

Elderly Patients

• Start with lower doses (1-2 mg/day in divided doses) 2
• Use more gradual tapering approach due to increased sensitivity 3

Pregnant Patients

• Consult specialists before tapering due to risks to mother and fetus 1, 3
• Opioid withdrawal during pregnancy has been associated with spontaneous abortion and premature labor 1

Patients with Comorbid Conditions

• For patients with respiratory issues or liver disease, use lorazepam (intermediate-acting) rather than long-acting benzodiazepines 1
• For patients with alcohol withdrawal syndrome, lorazepam is preferred at 6-12 mg/day initially, then tapered 1

Monitoring and Follow-up

• Weekly contact during active tapering period 3
• Monitor for:
  • Withdrawal symptoms
  • Changes in mood, anxiety, or suicidal ideation
  • Medication adherence to tapering schedule
  • Need for schedule adjustments

Common Pitfalls to Avoid

1. Tapering too quickly - This increases risk of withdrawal symptoms and failure
2. Using fixed taper schedules for all patients - Individualize based on response and duration of use
3. Abrupt discontinuation - This can lead to severe withdrawal including seizures
4. Inadequate patient education - Patients need to understand the process and potential symptoms
5. Ignoring psychological support - Cognitive-behavioral therapy and relaxation techniques improve success rates 3

Remember that successful tapering may take months, especially for long-term users, but is achievable with proper planning and monitoring.