What is the recommended first step when tapering and discontinuing alprazolam (Xanax) in a patient?

Alprazolam Tapering and Discontinuation Protocol

The recommended first step in tapering and discontinuing alprazolam is to convert to a longer-acting benzodiazepine at 100-125% equivalent dose (option C). 1

Rationale for Converting to Long-Acting Benzodiazepine

Converting to a longer-acting benzodiazepine before tapering provides several advantages:

• Smoother withdrawal process due to more gradual elimination
• Reduced severity of withdrawal symptoms
• Lower risk of seizures and other severe withdrawal complications
• More stable blood levels with less interdose withdrawal

The American College of Clinical Pharmacology recommends diazepam as the first choice for most patients due to its long half-life, with lorazepam preferred for patients with liver disease, respiratory issues, or advanced age 1.

Tapering Protocol After Conversion

After converting to a longer-acting benzodiazepine, follow this tapering schedule:

1. Reduce dose by 10% of the original dose per week
2. For long-term users, consider slower tapers (10% per month) which are better tolerated
3. Total duration of withdrawal typically lasts 8-12 weeks
4. Weekly monitoring during the active tapering period

Why Direct Alprazolam Tapering Is Not Recommended

Alprazolam has specific characteristics that make direct tapering problematic:

• Short half-life leading to interdose withdrawal
• Higher risk of withdrawal seizures, especially at doses above 4 mg/day
• More severe withdrawal symptoms compared to longer-acting benzodiazepines

The FDA label specifically notes: "There have been reports of failure of other benzodiazepines to fully suppress these withdrawal symptoms. These failures have been attributed to incomplete cross-tolerance but may also reflect the use of an inadequate dosing regimen of the substituted benzodiazepine." 2

Monitoring During Tapering

During the tapering process, monitor for:

• Withdrawal symptoms (anxiety, insomnia, tremor, nausea, vomiting)
• Changes in mood or anxiety
• Suicidal ideation
• Medication adherence to the tapering schedule

If withdrawal symptoms emerge, return to the previous dose and resume tapering at a slower rate 1.

Special Considerations

• High-risk patients (history of seizures, delirium, concurrent substance use): Require inpatient management
• Elderly patients: Use more gradual tapering approach
• Patients with liver disease: Consider lorazepam instead of diazepam for conversion

Common Pitfalls to Avoid

1. Tapering too rapidly: Can lead to severe withdrawal symptoms including seizures
2. Not recognizing withdrawal symptoms: May be confused with recurrence of underlying anxiety
3. Abrupt discontinuation: The FDA label explicitly warns against abrupt discontinuation of alprazolam, especially in patients with a history of seizures 2
4. Inadequate cross-coverage dosing: When converting to a longer-acting benzodiazepine, ensure adequate dosing (100-125% equivalent)

By following this evidence-based approach, the risk of withdrawal complications can be minimized while successfully discontinuing alprazolam therapy.