How do you wean someone off Ativan (lorazepam)?

Weaning Protocol for Ativan (Lorazepam)

To safely wean a patient from Ativan (lorazepam), implement a gradual tapering schedule of 10-20% dose reduction every 24-48 hours to prevent withdrawal symptoms, with the exact rate determined by duration of use and total daily dose. 1

Assessment of Withdrawal Risk

• Determine if the patient is at risk for withdrawal based on duration of use:

  • Use < 7 days: Generally can discontinue quickly with minimal risk of withdrawal 2
  • Use between 7-14 days: May need tapering but can be weaned more quickly 2
  • Use > 14 days: Will require a more gradual tapering protocol 2

• Monitor for signs of benzodiazepine withdrawal, which may include:

  • Anxiety, irritability, insomnia, tremor, headache, dizziness, tachycardia, hypertension, nausea, vomiting, and perceptual disturbances 1
  • More severe symptoms can include seizures, psychosis, and delirium 1

Tapering Protocol

For Short-Term Use (7-14 days)

• Reduce dose by 20% every 24-48 hours 2
• Monitor for withdrawal symptoms during each reduction 2

For Long-Term Use (>14 days)

• Develop a more gradual tapering schedule:
  • Aim to complete withdrawal in less than 6 months to avoid making the withdrawal process the focus of the patient's existence 3
  • Reduce dose by 10-20% of the original dose every 24-48 hours 2

Specific Lorazepam Tapering Strategy

1. Calculate the total daily dose of lorazepam 2
2. Divide the calculated dose into 4 doses given every 6 hours 2
3. Wean lorazepam by 10-20% per day 2
4. The dosage interval can also be gradually increased:
   • From every 6 hours → every 8 hours → every 12 hours → every 24 hours → every other day before discontinuation 2

Management During Withdrawal

• Closely monitor for withdrawal symptoms during the tapering process 2

• If withdrawal symptoms occur:

  • Administer the planned dose from the weaning schedule 2
  • Consider slowing the tapering rate if symptoms are severe 2

• Adjunctive medications that may help manage withdrawal symptoms:

  • Clonidine, gabapentin, or dexmedetomidine may be used to decrease withdrawal symptoms 2
  • Antidepressants may be helpful if the patient is depressed before or during withdrawal 3

Special Considerations

• Avoid abrupt discontinuation as it can precipitate life-threatening withdrawal reactions including seizures 1

• Higher risk patients for severe withdrawal include:

  • Those taking higher doses
  • Those with longer duration of use
  • Elderly patients
  • Patients with history of seizures 1

• Consider behavioral interventions to support the tapering process:

  • Cognitive-behavioral therapy has shown effectiveness in preventing relapse 3
  • Sleep hygiene education and anxiety management techniques 2

Common Pitfalls to Avoid

• Tapering too quickly, which can precipitate withdrawal symptoms 1

• Substituting one dependency for another 3

• Failing to monitor for protracted withdrawal syndrome, which can persist for weeks to more than 12 months 1

• Not recognizing that withdrawal symptoms may be confused with re-emergence of the original symptoms for which lorazepam was prescribed 1

• For patients on multiple sedatives or opioids, develop strategies to wean one medication at a time rather than attempting to wean from both simultaneously 2

Remember that successful withdrawal is associated with improved cognitive and psychomotor functioning, particularly in elderly patients 3.