How do I safely discontinue Xanax (alprazolam) XL?

Safely Discontinuing Xanax (Alprazolam) XL

Alprazolam should be discontinued gradually by reducing the dose by no more than 0.5 mg every 3 days to prevent withdrawal symptoms, with some patients requiring an even slower tapering schedule. 1

Assessment Before Tapering

• Document baseline symptoms, medication history including duration of use and daily dose before initiating withdrawal 2
• Patients at high risk for severe withdrawal (history of seizures, medical comorbidities) may require inpatient management 2
• Educate patients about potential withdrawal symptoms and benefits of tapering, as this approach has shown success in facilitating withdrawal 2

Tapering Protocol for Alprazolam

• Reduce the daily dose by no more than 0.5 mg every 3 days as recommended in the FDA label 1
• For long-term users, consider an even slower tapering schedule extending over several weeks to months 1, 2
• Some patients may require an extremely gradual taper, especially those on high doses or with prolonged use 1, 3
• If withdrawal symptoms become severe, temporarily return to the previous dose before continuing with a more gradual taper 2

Managing Withdrawal Symptoms

• Common withdrawal symptoms include insomnia (29.5%), anxiety (19.2%), light-headedness (19.3%), fatigue (18.4%), headache (17%), abnormal involuntary movements (17.3%), nausea/vomiting (16.5%), and sweating (14.4%) 1
• More serious withdrawal symptoms can include seizures, which have been reported with abrupt discontinuation 1, 4
• Use a standardized scoring system to assess withdrawal symptoms during the tapering process 2
• For breakthrough anxiety or agitation, consider using the lowest effective dose of alprazolam rather than adding different medications 2

Adjunctive Treatments

• Consider non-pharmacological interventions including cognitive-behavioral therapy, supportive psychotherapy, relaxation techniques, and patient education 2, 5
• Psychological support should be available both during dosage reduction and for some months after cessation 3
• Adjunctive medications may occasionally be required (antidepressants, propranolol) but no drugs have been proven to be of general utility in alleviating withdrawal symptoms 3

Special Considerations

• Elderly patients, those with advanced liver disease, or debilitating conditions may require starting at lower doses (0.25 mg) and more gradual tapering 1
• Success rates of withdrawal are high and are unaffected by duration of usage, dosage or type of benzodiazepine, rate of withdrawal, symptom severity, psychiatric history or personality disorder 3
• Unwilling patients should not be forced to withdraw 3

Follow-up and Monitoring

• Regular follow-up appointments to assess withdrawal symptoms and adjust the tapering schedule as needed 2
• Monitor for at least 2 months after discontinuation to distinguish between withdrawal symptoms and relapse 6
• Consider referral to addiction specialists for patients with severe dependence or complicated withdrawal 2

Common Pitfalls to Avoid

• Tapering too quickly, which can precipitate severe withdrawal symptoms including seizures 4, 7
• Abrupt discontinuation, which significantly increases risk of withdrawal syndrome and rebound symptoms 1, 8
• Failing to address underlying reasons for alprazolam use 2
• Underestimating the potential for withdrawal symptoms even in patients taking therapeutic doses for short periods 7