Lorazepam to Diazepam Tapering Regimen
When switching a patient from Ativan (lorazepam) to Valium (diazepam), use a gradual tapering schedule with an initial conversion ratio of 1 mg lorazepam to 10 mg diazepam, followed by a 5-10% dose reduction every 1-2 weeks based on withdrawal symptoms.
Conversion Principles
The conversion from lorazepam to diazepam requires careful consideration of their pharmacological differences:
- Potency difference: Lorazepam is approximately 10 times more potent than diazepam (1 mg lorazepam ≈ 10 mg diazepam) 1
- Pharmacokinetic differences:
- Diazepam has a longer half-life (20-100 hours) and active metabolites
- Lorazepam has an intermediate half-life (10-20 hours) with no active metabolites
Step-by-Step Tapering Protocol
1. Initial Assessment
- Evaluate current lorazepam dose, duration of use, and patient risk factors
- Screen for concurrent substance use, particularly opioids 1
- Assess for underlying psychiatric conditions requiring treatment
2. Conversion Process
- Day 1-3: Replace 50% of lorazepam dose with equivalent diazepam
- Day 4-7: Replace remaining 50% of lorazepam with equivalent diazepam
- Example: For a patient on 6 mg/day lorazepam
- Days 1-3: 3 mg lorazepam + 30 mg diazepam daily
- Days 4-7: 60 mg diazepam daily
3. Diazepam Tapering Schedule
- Standard taper: Reduce by 5-10% of the original dose every 1-2 weeks 1
- For high doses (>60 mg/day): Initial reductions can be larger (10-15%)
- For lower doses (<30 mg/day): Slower reductions (5% every 2 weeks)
4. Monitoring and Adjustment
- Assess for withdrawal symptoms before each dose reduction
- Common withdrawal symptoms include:
- Anxiety, irritability, insomnia
- Tremor, diaphoresis, agitation
- Hypertension, tachycardia
- Hyperalgesia, myoclonus 2
5. Special Considerations
Elderly Patients
- Use more gradual tapering (5% reduction every 2-4 weeks) 2, 1
- Start with lower initial diazepam equivalent dose (25-50% reduction)
Patients with Liver Disease
- Consider using a more gradual taper (2.5-5% reduction)
- Monitor for signs of over-sedation due to impaired metabolism 1
Patients with History of Seizures
- More gradual tapering is essential (2.5-5% every 2-4 weeks)
- Consider adjunctive anticonvulsant therapy during taper 1
Adjunctive Treatments for Withdrawal Symptoms
For specific withdrawal symptoms, consider the following medications 1:
- Sympathetic hyperactivity: Clonidine
- Insomnia: Trazodone, mirtazapine, or gabapentin
- Anxiety: Hydroxyzine
- Pain: Scheduled acetaminophen (not exceeding 3000mg daily)
Pitfalls to Avoid
- Too rapid tapering: Can precipitate severe withdrawal symptoms including seizures
- Incomplete conversion: Ensure full transition to diazepam before beginning taper
- Ignoring breakthrough symptoms: Adjust taper rate based on patient response
- Overlooking concurrent substance use: Particularly opioids or alcohol which may complicate withdrawal
Benefits of Using Diazepam for Tapering
Diazepam is preferred for tapering due to:
- Longer half-life providing smoother withdrawal
- Self-tapering effect from active metabolites
- Lower incidence of breakthrough symptoms and rebound phenomena
- Decreased seizure risk during withdrawal 3
The gradual, symptom-based approach to tapering is safe and effective even in patients with liver disease or elderly patients when properly monitored 3.