Clonidine for Benzodiazepine Discontinuation
Clonidine is not recommended for benzodiazepine discontinuation as evidence shows it is ineffective in reducing withdrawal symptoms and may cause additional adverse effects.
Evidence on Clonidine for Benzodiazepine Withdrawal
Ineffectiveness in Benzodiazepine Withdrawal
- A double-blind, placebo-controlled study found that clonidine did not alter the intensity, severity, or duration of benzodiazepine abstinence syndrome, despite doses sufficient to reduce blood pressure and plasma catecholamines 1
- This contrasts with clonidine's established efficacy in opioid withdrawal, suggesting that benzodiazepine withdrawal symptoms may not be primarily caused by noradrenergic hyperactivity 1
- A review of pharmacologic approaches for benzodiazepine discontinuation found clonidine to be "inconsistently effective" in attenuating physiologic withdrawal symptoms 2
Limited Positive Evidence
- A pilot study with alprazolam discontinuation in panic disorder patients using adjunctive clonidine (0.15-0.7 mg/day) showed that while more patients successfully discontinued benzodiazepines compared to a previous non-clonidine trial, 10 of 12 patients still experienced new withdrawal symptoms and 11 of 12 experienced recurrent panic attacks during tapering 3
- The authors concluded that clonidine did not appear to have a specific effect on relapse or withdrawal, and a placebo-controlled trial would be needed to determine if any benefits were due to clonidine itself or other factors 3
Recommended Benzodiazepine Tapering Approach
Standard Tapering Protocol
- Current guidelines recommend a gradual tapering method with dose reductions of approximately 25% every 1-2 weeks 4
- The tapering schedule should be adjusted based on the patient's withdrawal symptoms and tolerance 4
- For elderly patients, more conservative tapering with slower and smaller reductions is recommended 4
Alternative Pharmacologic Strategies
- Carbamazepine, imipramine, valproate, and trazodone have shown benefits in managing benzodiazepine discontinuation, though they don't decrease the severity of withdrawal symptoms 5
- For anxiety disorders, alternative treatments such as SSRIs, SNRIs, or buspirone can be considered 4
Non-Pharmacological Support
- Cognitive behavioral therapy significantly increases tapering success rates 4
- Relaxation techniques, sleep hygiene education, and support groups can be beneficial during benzodiazepine deprescribing 4
- Patient education is crucial - the EMPOWER trial showed 27% of seniors stopped benzodiazepines when educated about risks 4
Management of Withdrawal Symptoms
Monitoring and Assessment
- Regular assessment for withdrawal symptoms, vital sign stability, and emergence of underlying anxiety or depression is necessary 4
- The tapering schedule should be adjusted based on patient tolerance, with slower tapering if withdrawal symptoms are severe 4
Treatment of Severe Symptoms
- For severe agitation during withdrawal, short-term use of antipsychotics like olanzapine (2.5-5 mg), quetiapine (25 mg), or risperidone (0.5 mg) may be considered 4
- Caution is needed when combining benzodiazepines with olanzapine due to risks of oversedation and respiratory depression 4
Conclusion
Based on the available evidence, clonidine should not be used as an adjunctive treatment for benzodiazepine withdrawal. The most recent and highest quality studies demonstrate its ineffectiveness in this context, despite its utility in other withdrawal syndromes such as alcohol and opioids. A structured tapering protocol with appropriate non-pharmacological support and possibly other pharmacological adjuncts (such as carbamazepine) represents the most evidence-based approach to benzodiazepine discontinuation.