What alternatives are available to manage anxiety in a patient on an Ativan (lorazepam) taper?

Alternatives to Lorazepam for Anxiety Management During Benzodiazepine Tapering

For patients undergoing Ativan (lorazepam) tapering, evidence-based psychotherapies (particularly cognitive behavioral therapy) and specific non-benzodiazepine medications such as buspirone or certain antidepressants should be offered as alternatives for anxiety management.

Non-Benzodiazepine Medication Alternatives

• Buspirone is an effective anxiolytic with no sedative, anticonvulsant, or muscle relaxant properties, making it "anxioselective" and particularly useful during benzodiazepine tapering 1, 2
• Buspirone has significantly fewer sedative effects (16% vs 65% for lorazepam) while providing comparable anxiety relief 3
• Typical dosing is 15-30 mg/day, though onset of action may take 1-2 weeks 1
• Specific antidepressants can be effective for anxiety management during benzodiazepine tapering:
  • Imipramine has been shown to significantly increase benzodiazepine taper success rates (82.6% vs 37.5% with placebo) 2
  • Trazodone, tricyclic antidepressants, and mirtazapine can help mitigate anxiety, insomnia, and irritability during tapering 4

Evidence-Based Non-Pharmacological Approaches

• Cognitive behavioral therapy (CBT) increases benzodiazepine tapering success rates and is particularly helpful for patients struggling with the taper 4
• Interdisciplinary approaches incorporating psychosocial treatments (CBT, mindfulness stress reduction, relaxation training) and rehabilitation (physical therapy, graded exercise) have shown beneficial outcomes 4

Adjunctive Medications for Withdrawal Symptom Management

• α2-Agonists directly attenuate opioid withdrawal symptoms:
  • Clonidine can suppress withdrawal symptoms but requires careful titration due to potential hypotension 4
  • Tizanidine is less effective but also less likely to cause hypotension 4
• Gabapentin may help mitigate anxiety, insomnia, and irritability during tapering 4

Tapering Considerations

• A gradual taper is essential to reduce withdrawal risks - a common successful approach is reducing benzodiazepine dose by 25% every 1-2 weeks 4
• Benzodiazepines should be tapered gradually as abrupt withdrawal can cause rebound anxiety, hallucinations, seizures, and rarely death 4

Important Cautions

• Avoid concurrent use of benzodiazepines with opioids whenever possible, as this combination increases risk of fatal respiratory depression 4, 5
• Benzodiazepines can cause sedation, cognitive impairment, and unsafe mobility with risk of injurious falls, particularly in older adults 4
• Paradoxical agitation occurs in approximately 10% of patients treated with benzodiazepines 6

Clinical Decision Algorithm

1. First-line: Initiate CBT or other evidence-based psychotherapy while continuing the planned lorazepam taper 4
2. Second-line: Add buspirone 15-30 mg/day (starting at lower doses and titrating up) 1, 3
3. Third-line: Consider specific antidepressants based on symptom profile:
   • For prominent anxiety with insomnia: Trazodone or mirtazapine 4
   • For anxiety with depression: Imipramine or other tricyclic antidepressants 2
4. For breakthrough anxiety: Use non-pharmacological techniques (breathing exercises, mindfulness) rather than increasing lorazepam 4

Remember that benzodiazepine withdrawal can be associated with rebound anxiety, hallucinations, seizures, and rarely death, so careful monitoring during the tapering process is essential 4.