What is a recommended tapering plan for lorazepam (Ativan)?

Lorazepam Tapering Protocol

For safe discontinuation of lorazepam, implement a gradual taper with 10% reduction of the most recent dose every 2-4 weeks, with slower tapers (10% per month) for long-term users to minimize withdrawal symptoms. 1

Initial Assessment and Preparation

• Evaluate the patient's duration of lorazepam use, as longer-term users (≥1 year) require slower tapers 2
• Obtain patient agreement and involvement in the tapering plan to improve success rates 1, 2
• Set realistic expectations about the tapering process and potential withdrawal symptoms 1

Recommended Tapering Schedule

• For standard cases: Reduce dose by 10% of the most recent dose every 2-4 weeks 1, 2
• For long-term users: Consider slower reductions of 10% per month or less 1, 2
• Example for 2mg daily dose:
  • First reduction: 1.8mg daily (10% reduction) 2
  • Second reduction: 1.62mg daily (10% of 1.8mg) 2
  • Continue with 10% reductions of each new dose 2

Monitoring During Taper

• Monitor for withdrawal symptoms after each dose reduction before proceeding to the next step 1
• Common withdrawal symptoms include:
  • Anxiety, tension, and insomnia 3
  • Shaking/trembling/tremor 4
  • Nausea/vomiting 4
  • Excessive sweating 4
  • Tachycardia/palpitations 4
  • Headache and muscle aches 4

Managing Withdrawal Symptoms

• If withdrawal symptoms become severe, return to the previous well-tolerated dose and slow the taper further 1
• Consider adjunctive medications for specific withdrawal symptoms:
  • For autonomic symptoms: α2-adrenergic agonists like clonidine 1, 2
  • For insomnia: short-term use of non-benzodiazepine sleep aids 1
  • For muscle aches: acetaminophen or NSAIDs 1

Special Considerations

• Final doses before complete cessation may need to be very small (as low as 0.25mg or less) to prevent a large decrease in receptor activity when stopped 5, 6
• For patients with a history of seizures, implement even slower tapering 2
• If the patient is also taking opioids, consider tapering the benzodiazepine first 2
• Never abruptly discontinue lorazepam except in cases of confirmed diversion or serious medical toxicity 1

Follow-up and Support

• Monitor patients at least monthly during the tapering process 2
• Incorporate non-pharmacological approaches:
  • Cognitive behavioral therapy 2
  • Exercise and physical activity 2
  • Stress management techniques 2
• Never abandon patients who are struggling with the taper; consider pausing rather than discontinuing care 1

Common Pitfalls to Avoid

• Tapering too quickly (less than 10% reduction every 2-4 weeks) 1, 4
• Setting arbitrary time limits for completing the taper 1
• Failing to recognize that withdrawal symptoms may be mistaken for recurrence of the original condition 5
• Underestimating the potential for rebound insomnia, which can be several times worse than baseline sleep disturbance 3