What is the recommended protocol for tapering someone off Xanax (alprazolam)?

Alprazolam (Xanax) Tapering Protocol

The recommended protocol for tapering alprazolam is to reduce the daily dosage by no more than 0.5 mg every 3 days, with some patients requiring an even slower reduction schedule to minimize withdrawal symptoms. 1

Initial Assessment and Planning

• Determine current daily dose of alprazolam
• Assess for concurrent substance use, especially opioids (taper opioids first if present)
• Evaluate for history of seizures, anxiety disorders, or other conditions that may require slower tapering
• Consider patient factors:
  • Elderly patients need more gradual tapering (5% reduction every 2 weeks)
  • Patients with hepatic impairment should start with 50% dose reduction
  • Patients with renal impairment should start with 25-50% dose reduction

Standard Tapering Schedule

For most patients, follow this FDA-recommended approach:

1. Reduce daily dose by no more than 0.5 mg every 3 days 1
2. Distribute doses evenly throughout the day to minimize interdose withdrawal symptoms
3. For doses greater than 4 mg/day, consider initial larger reductions, then slow to 0.5 mg every 3 days when reaching lower doses

Alternative Tapering Approaches

For patients experiencing significant withdrawal symptoms with standard tapering:

• Implement more gradual reduction: 5-10% of original dose every 1-2 weeks 2
• For very sensitive patients: 5% reduction every 2-4 weeks 2
• Consider hyperbolic tapering to very small doses before complete discontinuation

Withdrawal Symptom Management

Common withdrawal symptoms include:

• Anxiety, irritability, insomnia
• Tremor, diaphoresis, agitation
• Hypertension, tachycardia
• Hyperalgesia, myoclonus

Adjunctive medications for symptom management:

• Clonidine for sympathetic hyperactivity
• Trazodone or hydroxyzine for insomnia and anxiety
• Gabapentin for insomnia and anxiety
• Acetaminophen (max 3000mg daily) for pain 2

Supportive Interventions

• Cognitive behavioral therapy significantly increases tapering success rates 2
• Implement sleep hygiene practices, regular exercise, and stress management techniques
• Provide regular follow-up to assess withdrawal symptoms before each dose reduction
• Reinstate previous dosing if significant withdrawal symptoms develop, then restart with slower taper

Special Considerations

• For high-dose users (>4 mg/day), periodic reassessment during tapering is advised
• Pregnant women require specialist supervision during tapering
• Consider inpatient treatment for patients with history of withdrawal seizures or delirium tremens
• Some patients may benefit from substitution with a longer-acting benzodiazepine like chlordiazepoxide (50 mg for each 1 mg of alprazolam) 3

Common Pitfalls to Avoid

• Tapering too quickly (increases risk of withdrawal symptoms and failure)
• Mistaking withdrawal symptoms for recurrence of underlying anxiety disorder
• Stopping at therapeutic minimum doses rather than tapering to much lower doses
• Failing to provide adequate psychosocial support during tapering
• Attempting to taper patients with unstable psychiatric conditions

The evidence strongly suggests that slow, gradual tapering is more successful than rapid discontinuation. While the FDA label recommends 0.5 mg reduction every 3 days 1, many patients benefit from even slower schedules, especially those on long-term therapy or with complicating factors 2, 4.