Is it better to convert to diazepam (a benzodiazepine) and then taper, rather than directly tapering temazepam (a benzodiazepine)?

Converting to Diazepam for Benzodiazepine Tapering

Converting from temazepam to diazepam before tapering is generally recommended as it provides a smoother withdrawal experience with fewer breakthrough symptoms due to diazepam's longer half-life.

Why Convert to Diazepam?

Diazepam offers several advantages when tapering from benzodiazepines:

• Longer half-life: Diazepam and its active metabolite desmethyldiazepam have longer elimination half-lives, creating a natural, gradual self-tapering effect 1
• Smoother withdrawal: The gradual decrease in blood levels results in lower incidence and severity of breakthrough symptoms and rebound phenomena 1
• Dosing flexibility: Diazepam is available in multiple strengths and liquid formulation, allowing for more precise tapering schedules 2
• Reduced seizure risk: The longer half-life may decrease the risk of withdrawal seizures compared to directly tapering shorter-acting benzodiazepines like temazepam 3

Conversion and Tapering Protocol

1. Initial conversion: Calculate equivalent dose of diazepam to current temazepam dose

   • Temazepam 15-30 mg is approximately equivalent to diazepam 5-10 mg

2. Stabilization period: Allow 1-2 weeks on equivalent diazepam dose before beginning taper

3. Gradual tapering schedule:

   • Reduce dose by 10-25% of the most recent dose every 2-4 weeks 4
   • Slow the taper to 5-10% reductions at lower doses 4
   • For patients on benzodiazepines >1 year, consider even slower tapering at 10% per month 4

4. Monitoring: Weekly assessment for withdrawal symptoms during active tapering period 4

Managing Withdrawal Symptoms

Common withdrawal symptoms may include:

• Anxiety, insomnia, tremor
• Autonomic symptoms (tachycardia, hypertension)
• Gastrointestinal distress
• Perceptual changes, irritability 5

Adjunctive treatments for withdrawal symptoms:

• α2-Agonists (clonidine, tizanidine) for autonomic symptoms 4
• Gabapentin for anxiety, insomnia, and irritability 4
• Trazodone specifically for insomnia 4
• Non-pharmacological approaches: Cognitive-behavioral therapy, relaxation techniques 4, 2

Special Considerations

• Risk of seizures: Abrupt discontinuation of benzodiazepines can precipitate withdrawal seizures. This risk is higher with short-acting benzodiazepines like temazepam compared to long-acting ones like diazepam 3

• Elderly patients: Use medications with caution due to increased sensitivity to adverse effects; consider a more gradual tapering approach 4

• Failure of tapering: If withdrawal symptoms become severe, pause the taper or return to the previous dose before attempting a slower taper 5

Evidence Supporting Diazepam Conversion

A double-blind, placebo-controlled trial found that patients who were abruptly switched to placebo experienced more severe withdrawal symptoms compared to those who received tapering doses of diazepam. Additionally, withdrawal symptoms occurred earlier in patients who had received short-acting benzodiazepines compared to those on long-acting benzodiazepines 6.

The FDA label for temazepam specifically recommends: "To reduce the risk of withdrawal reactions, use a gradual taper to discontinue temazepam or reduce the dosage" 5. Converting to diazepam provides an effective method to achieve this gradual taper.

Remember that successful withdrawal is associated with improved psychomotor and cognitive functioning, particularly in elderly patients 2. While the process may be challenging, the outcome is generally gratifying in terms of improved functioning and discontinuation of benzodiazepine use.