What are the guidelines for tapering Ativan (lorazepam)?

Lorazepam (Ativan) Tapering Guidelines

For patients on long-term lorazepam therapy, a gradual taper of 10% per month or slower is recommended to minimize withdrawal symptoms and ensure patient safety. 1

Understanding Lorazepam Withdrawal Risks

Lorazepam is a benzodiazepine with significant potential for physical dependence. Abrupt discontinuation can lead to serious withdrawal symptoms including:

• Anxiety and panic
• Insomnia
• Tremors
• Seizures (potentially life-threatening)
• Psychosis
• Autonomic instability (tachycardia, hypertension)

The FDA drug label explicitly warns that "to reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage" and that "a patient-specific plan should be used to taper the dose." 2

Recommended Tapering Protocol

Initial Assessment

• Determine duration of use, current dose, and reason for prescription
• Assess for history of previous withdrawal symptoms or seizures
• Screen for concurrent substance use (especially opioids)

Standard Tapering Schedule

1. For long-term users (≥1 year):

   • Reduce dose by 10% per month or slower 1
   • Example: 2mg daily → 1.8mg daily for one month → 1.6mg daily for one month, etc.

2. For shorter-term users (<1 year):

   • Consider slightly faster tapering (10-25% every 1-2 weeks)
   • Slow down taper as lower doses are reached

3. Final phase of tapering:

   • Slow the taper further at lower doses (e.g., 5% reductions)
   • May need to use liquid formulations for precise dosing at very low doses

Monitoring and Support

• Follow up at least monthly during tapering 1
• Assess for withdrawal symptoms at each visit
• Consider weekly contact during active tapering period 1

Managing Withdrawal Symptoms

Common withdrawal symptoms include anxiety, insomnia, tremor, and autonomic symptoms. If significant symptoms emerge:

• Pause the taper temporarily
• Resume at a slower rate when symptoms stabilize
• Consider adjunctive medications:
  • Propranolol for autonomic symptoms
  • Non-benzodiazepine sleep aids for insomnia
  • Anticonvulsants if seizure risk is high

Special Considerations

Elderly Patients

• Use more gradual tapering (5% or less per month)
• Monitor closely for confusion, falls, and cognitive changes 1

Patients with History of Seizures

• Consider inpatient management
• More gradual tapering is essential
• Anticonvulsant coverage may be warranted 1

Concurrent Opioid Use

• Requires extra caution due to increased risk of respiratory depression
• Lower initial doses of both medications are recommended 2
• Consider addiction specialist consultation 1

Non-Pharmacological Support

Cognitive-behavioral therapy and relaxation techniques significantly improve success rates of benzodiazepine tapering 1. Consider:

• Stress management techniques
• Sleep hygiene education
• Mindfulness practices
• Supportive psychotherapy

Clinical Pitfalls to Avoid

1. Never discontinue lorazepam abruptly unless there are life-threatening issues 1
2. Avoid "cold referrals" to clinicians who have not agreed to accept the patient 3
3. Don't use linear tapering - percentage reductions should be based on the most recent dose, not the starting dose 3
4. Don't overlook protracted withdrawal syndrome - symptoms can persist for weeks to more than 12 months after discontinuation 2

Alternative Approaches

For patients struggling with traditional tapering:

• Consider substituting diazepam (longer half-life) before tapering 4
• Some evidence suggests carbamazepine may assist with benzodiazepine discontinuation 4
• Buspirone may help manage anxiety during withdrawal, though evidence for improving completion rates is limited 5

By following these guidelines, clinicians can help patients safely discontinue lorazepam while minimizing withdrawal symptoms and maintaining quality of life.