What is the recommended tapering protocol for sedation medications, such as lorazepam (Ativan) or midazolam, when a patient is leaving Against Medical Advice (AMA)?

Tapering Protocol for Sedation Medications When Patients Leave AMA

For patients leaving Against Medical Advice (AMA) who have been on sedation medications like lorazepam (Ativan) or midazolam, a gradual tapering approach with a 25% dose reduction weekly over 4-6 weeks is recommended to minimize withdrawal symptoms and reduce morbidity and mortality risks. 1

Initial Assessment and Risk Stratification

When a patient decides to leave AMA while on sedation medications:

1. Determine duration of sedation medication use:

   • Short-term use (<7 days): May be able to discontinue more rapidly
   • Long-term use (>7 days): Requires more gradual tapering

2. Assess for risk factors that necessitate slower tapering:

   • History of seizures
   • Advanced age
   • Liver dysfunction
   • Concurrent opioid or alcohol use
   • Previous withdrawal symptoms

Recommended Tapering Protocol for Benzodiazepines

For Lorazepam (Ativan):

• Week 1-2: Reduce dose by 25% of original dose 1, 2
• Week 3-4: Reduce by another 25% (now at 50% of original dose)
• Week 5-6: Reduce by another 25% (now at 25% of original dose)
• Week 7-8: Discontinue completely

For example, if patient was on lorazepam 2mg TID (6mg/day):

• Week 1-2: 4.5mg/day (1.5mg TID)
• Week 3-4: 3mg/day (1mg TID)
• Week 5-6: 1.5mg/day (0.5mg TID)
• Week 7-8: Discontinue

For Midazolam:

Due to midazolam's shorter half-life, consider:

1. Converting to equivalent dose of longer-acting benzodiazepine (lorazepam)
2. Then follow the tapering schedule above

Monitoring and Symptom Management

Instruct patients to monitor for withdrawal symptoms:

• Anxiety, irritability, insomnia
• Tremors, sweating, tachycardia
• Nausea, vomiting
• Seizures (rare but serious)

Managing Withdrawal Symptoms

• For anxiety/agitation: If severe, slow the taper rate
• For insomnia: Recommend sleep hygiene measures; consider temporary melatonin 1
• For autonomic symptoms: Consider clonidine if severe 1

Special Considerations

1. Patients with seizure history: Taper more slowly (10-15% reduction every 2-3 weeks) 3

2. Elderly patients: Start with lower doses and taper more gradually; use shorter-acting benzodiazepines like lorazepam rather than long-acting ones 2

3. Patients with liver dysfunction: Use lorazepam rather than diazepam as it doesn't rely on hepatic metabolism 3

4. Concurrent substance use: Coordinate with addiction specialists if possible; these patients are at higher risk for complications 1

Documentation and Follow-up

Provide written instructions including:

1. Clear tapering schedule with exact doses
2. Warning signs requiring medical attention
3. Follow-up appointment schedule (ideally weekly during first month)

Common Pitfalls to Avoid

• Avoid abrupt discontinuation which significantly increases seizure risk and can be life-threatening 2
• Don't substitute with other sedatives (particularly alcohol) as this may lead to cross-dependence 1, 3
• Don't mistake return of original symptoms for withdrawal - distinguish between the two to guide management 1

When to Seek Immediate Medical Attention

Instruct patients to seek immediate medical care for:

• Seizures
• Severe confusion or hallucinations
• Significant vital sign abnormalities (high fever, severe hypertension)
• Suicidal ideation

While hyperbolic tapering (exponential dose reduction) may be more effective for minimizing withdrawal symptoms 4, the 25% weekly reduction approach is more practical and easier to implement in patients leaving AMA 1.