What is the recommended approach for de-prescribing benzodiazepines (BZDs) in patients?

Benzodiazepine De-prescribing Approach

The recommended approach for de-prescribing benzodiazepines is a gradual tapering method with dose reductions of approximately 25% every 1-2 weeks, preferably using a long-acting benzodiazepine substitution such as diazepam. 1

Initial Assessment and Planning

• Evaluate the patient's current benzodiazepine use:

  • Duration of use
  • Current dose
  • Type of benzodiazepine
  • Indication for use
  • Previous withdrawal attempts

• For patients on short-acting benzodiazepines (e.g., alprazolam), consider switching to an equivalent dose of a long-acting benzodiazepine:

  • Diazepam is preferred due to its long half-life and reduced risk of rebound anxiety
  • Conversion ratio: 10mg diazepam ≈ 0.5mg alprazolam 1

Tapering Protocol

1. Standard Tapering Schedule:

   • Reduce dose by approximately 25% every 1-2 weeks 2, 1
   • Adjust based on patient's withdrawal symptoms and tolerance
   • Slower tapering may be needed if withdrawal symptoms are severe

2. Special Populations:

   • Elderly patients: More conservative tapering with smaller reductions 1
   • Patients with liver disease: May require dose adjustments due to altered metabolism
   • History of seizures: May need specialized care and slower tapering

Managing Withdrawal Symptoms

• Regular monitoring for withdrawal symptoms:

  • Anxiety, insomnia, irritability, tremors
  • Sensory hypersensitivity
  • Muscle tension, headaches
  • In severe cases: seizures, psychosis

• Non-pharmacological interventions:

  • Cognitive behavioral therapy (significantly increases tapering success rates) 1
  • Relaxation techniques
  • Sleep hygiene education

• For severe withdrawal symptoms:

  • Consider temporary slowing of taper
  • Short-term use of adjunctive medications may be considered for specific symptoms

Evidence for Effectiveness

Benzodiazepine deprescribing success rates vary between 27% and 80%, depending on the intervention approach 3, 4. The highest success rates are seen with:

• Gradual tapering with non-pharmacological support versus tapering alone 3
• Patient education combined with tapering protocols 5
• Multidisciplinary approaches involving physicians, pharmacists, and patients 4

Important Considerations and Cautions

• Abrupt discontinuation should be avoided due to risk of withdrawal seizures, especially with doses above 4 mg/day (alprazolam equivalent) 6
• Withdrawal symptoms can range from mild dysphoria and insomnia to a major syndrome including abdominal cramps, vomiting, sweating, tremors, and convulsions 6
• Withdrawal symptoms may be difficult to distinguish from recurrence of the original condition (e.g., anxiety) 6
• Patients with a history of alcohol or drug abuse require additional caution and monitoring 7

Patient Education

• Explain the risks of long-term benzodiazepine use:

  • Dependence and tolerance
  • Cognitive impairment
  • Increased risk of falls and fractures (especially in elderly)
  • Potential for withdrawal symptoms

• Set realistic expectations about the tapering process:

  • Temporary increase in symptoms is common
  • Success rates improve with proper support
  • The process may take several months for long-term users

Alternative Treatments

For the underlying condition that prompted benzodiazepine use:

• For anxiety disorders:

  • SSRIs or SNRIs
  • Buspirone
  • Cognitive behavioral therapy

• For insomnia:

  • Sleep hygiene education
  • Cognitive behavioral therapy for insomnia (CBT-I)
  • Consider safer alternatives if pharmacotherapy is needed

The evidence strongly supports that benzodiazepine deprescribing is feasible and successful when implemented with appropriate tapering schedules and support mechanisms, with gradual tapering combined with non-pharmacological support showing the best outcomes 3, 5.