What benzodiazepine should a patient be switched to when discontinuing triazolam (triazolam) and how to proceed with tapering?

Switching from Triazolam and Benzodiazepine Tapering Protocol

For a 59-year-old female patient who wants to discontinue triazolam, I recommend switching to lorazepam and implementing a gradual taper to minimize withdrawal symptoms. 1

Medication Selection for Switch

• Lorazepam is the preferred benzodiazepine for switching from triazolam due to its intermediate half-life (10-20 hours), which provides smoother blood levels during tapering compared to triazolam's ultra-short half-life (2-5 hours) 2, 3
• Equivalent dose conversion: Triazolam 0.25mg is approximately equivalent to lorazepam 1mg 1
• Avoid switching to long-acting benzodiazepines like clonazepam in older adults due to increased risk of daytime sedation and falls 4

Tapering Protocol

• Begin with patient education about withdrawal symptoms and the benefits of gradual tapering 1
• Initial stabilization: Convert to equivalent lorazepam dose and divide into twice daily dosing 1
• Reduce total daily dose by 10-25% every 2-4 weeks (slower is better for patients on long-term therapy) 4, 1
• For patients who have been taking benzodiazepines for ≥1 year, tapers of 10% per month or slower are better tolerated 4
• As the patient reaches lower doses (below 1mg lorazepam daily), slow the taper further to 5-10% reductions 1, 5

Sample Tapering Schedule

Assuming the patient was on triazolam 0.25mg nightly (equivalent to lorazepam 1mg):

• Weeks 1-2: Lorazepam 0.5mg twice daily (total 1mg/day)
• Weeks 3-4: Lorazepam 0.5mg morning, 0.25mg evening (total 0.75mg/day)
• Weeks 5-6: Lorazepam 0.25mg twice daily (total 0.5mg/day)
• Weeks 7-8: Lorazepam 0.25mg daily
• Weeks 9-10: Lorazepam 0.25mg every other day
• Weeks 11-12: Discontinue 1, 5

Monitoring and Management During Taper

• Schedule follow-up appointments at least monthly during the taper 4
• Monitor for withdrawal symptoms: anxiety, insomnia, tremor, irritability, perceptual disturbances, nausea, headache, muscle pain, and seizures 6
• If withdrawal symptoms become significant, pause the taper temporarily and resume at a slower rate 4, 1
• Clinically significant withdrawal symptoms signal the need to slow the taper rate 4

Adjunctive Treatments

• Maximize non-pharmacological treatments for anxiety and insomnia during the taper 4, 1:
  • Cognitive behavioral therapy for insomnia (CBT-I) 4
  • Relaxation techniques and sleep hygiene education 4
  • Regular physical activity 1
• Consider non-benzodiazepine medications for managing specific symptoms if needed:
  • For anxiety: Buspirone (non-addictive, non-sedating) 1
  • For physical withdrawal symptoms: Clonidine (helps with autonomic symptoms) 1

Common Pitfalls to Avoid

• Never discontinue benzodiazepines abruptly as this can lead to severe withdrawal including seizures, delirium, and in rare cases, death 4, 6
• Avoid prescribing other CNS depressants during the taper period 4
• Don't taper too quickly, especially in patients with a history of long-term use 4, 5
• Be aware that withdrawal symptoms may persist for weeks to months after discontinuation (protracted withdrawal) 1
• If the patient has comorbid opioid use, taper the benzodiazepine first before addressing opioid tapering 4

Special Considerations for This Patient

• At age 59, the patient may be more sensitive to withdrawal effects and may require a slower taper 4
• If the patient has been using triazolam for many years, expect the taper to take several months 4
• Assess for any underlying psychiatric conditions that may emerge during the taper and require treatment 4, 1
• Document the rationale for the taper and the patient's agreement with the plan 1