Tapering Protocol for Ativan (Lorazepam) 1mg BID
A gradual taper of Ativan 1mg twice daily should be implemented with a reduction of 25% every 1-2 weeks, which has been shown to be safe and moderately successful for benzodiazepine discontinuation. 1
Understanding Risks of Abrupt Discontinuation
- Abrupt discontinuation of benzodiazepines like Ativan can cause serious withdrawal symptoms including rebound anxiety, hallucinations, seizures, delirium tremens, and in rare cases, death 1
- Lorazepam can produce physical dependence with continued therapy, manifested by withdrawal signs and symptoms after abrupt discontinuation or significant dose reduction 2
- The FDA has issued a boxed warning that abrupt discontinuation or rapid dosage reduction of lorazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening 2
Recommended Tapering Approach
Initial Assessment and Planning
- Collaborate with the patient on the tapering plan, including decisions about tapering speed and when pauses might be warranted 1
- Set realistic expectations with the patient regarding individualized goals, potential withdrawal symptoms, and contingency plans should problems arise 1
- Communicate clearly that you are not abandoning the patient but helping them safely discontinue the medication 1
Specific Tapering Schedule
- For a patient on Ativan 1mg BID (total 2mg daily):
- Begin with a reduction of 25% (0.5mg) every 1-2 weeks 1
- Initial reduction: Decrease to 1.5mg daily (e.g., 0.75mg BID or 1mg morning/0.5mg evening)
- After 1-2 weeks: Decrease to 1mg daily (0.5mg BID)
- After another 1-2 weeks: Decrease to 0.5mg daily (0.5mg once daily)
- After another 1-2 weeks: Discontinue completely
- For patients who have been taking lorazepam long-term (≥1 year), consider an even slower taper of 10% per month 1
- The taper rate should be determined by the patient's ability to tolerate it 1
Managing Withdrawal Symptoms
Common withdrawal symptoms include:
Adjunctive medications to consider for withdrawal symptoms:
- α2-Agonists like clonidine can directly attenuate withdrawal symptoms (start with small doses due to potential hypotension) 1
- Tizanidine is less effective but also less likely to cause hypotension 1
- For short-term use: trazodone, tricyclic antidepressants, gabapentin, or mirtazapine may help with anxiety, insomnia, and irritability 1
- For gastrointestinal discomfort: loperamide (monitor for potential abuse) 1
Special Considerations
- Cognitive behavioral therapy (CBT) increases tapering success rates and might be particularly helpful for patients struggling with benzodiazepine tapering 1
- If the patient is also taking opioids, it is generally safer to taper benzodiazepines before opioids due to greater risks of benzodiazepine withdrawal 1
- For patients who cannot tolerate the taper, consider pausing the taper temporarily and restarting when the patient is ready 1
- Follow up frequently (at least monthly) with patients undergoing benzodiazepine tapering 1
Potential Pitfalls and Caveats
- Avoid "cold referrals" to clinicians who have not agreed to accept the patient, as this constitutes patient abandonment 1
- Be aware that protracted withdrawal syndrome may occur months after discontinuation, with symptoms including dysphoria, irritability, insomnia, and anhedonia 1
- Percentage reductions should not follow a straight-line taper; each new dose should be a percentage of the previous dose 1
- The target dose may not be zero for all patients; some may benefit from resumption at lower doses if complete discontinuation is not tolerable 1
By following this evidence-based approach to Ativan tapering, you can minimize withdrawal symptoms and maximize the chances of successful discontinuation while prioritizing patient safety and comfort.