How to taper alprazolam (Xanax) 2mg three times a day (TID) and temazepam (Restoril) 30mg every night at bedtime (QHS) in a patient taking both medications?

Benzodiazepine Tapering Protocol for Patient on Alprazolam and Temazepam

The safest approach is to taper alprazolam first with a gradual reduction of 0.5 mg every 3 days, followed by temazepam tapering after alprazolam is completely discontinued. 1, 2

Initial Assessment and Planning

• Benzodiazepines should be tapered gradually to avoid withdrawal symptoms, which can include seizures and, rarely, death 1
• Regular use of benzodiazepines can lead to tolerance, addiction, depression, and cognitive impairment 3
• When a patient is taking both alprazolam and temazepam, it's safer to discontinue one medication completely before starting to taper the other 1

Alprazolam Tapering Protocol

• Begin with the current dose of alprazolam (2mg TID = 6mg daily) 2

• Reduce the dose by no more than 0.5 mg every 3 days 2

• A suggested schedule would be:

  • Week 1: 2mg morning, 2mg afternoon, 1.5mg evening (5.5mg total) 2
  • Week 2: 1.5mg morning, 1.5mg afternoon, 1.5mg evening (4.5mg total) 2
  • Week 3: 1.5mg morning, 1mg afternoon, 1mg evening (3.5mg total) 2
  • Week 4: 1mg morning, 1mg afternoon, 1mg evening (3mg total) 2
  • Continue this pattern until reaching zero 2, 1

• Some patients may require an even slower taper, especially those who have been on the medication for a long time 2, 4

• If significant withdrawal symptoms develop, return to the previous dosage and stabilize before attempting a slower taper 2

Temazepam Tapering Protocol

• After successfully discontinuing alprazolam, begin tapering temazepam 1
• Start with the current dose of temazepam (30mg QHS) 5
• Reduce by 5-10mg every 1-2 weeks 1
• A suggested schedule would be:
  • Weeks 1-2: 20mg QHS 5
  • Weeks 3-4: 15mg QHS 5
  • Weeks 5-6: 10mg QHS 5
  • Weeks 7-8: 5mg QHS 5
  • Then discontinue 5

Monitoring During Tapering

• Monitor for withdrawal symptoms including:
  • Anxiety, insomnia, tremors, sweating, tachycardia 6
  • Nausea, vomiting, headache, muscle aches 6
  • Seizures (rare but serious) 1
• If withdrawal symptoms become severe, slow the taper further 1, 2

Adjunctive Strategies

• Consider cognitive behavioral therapy (CBT) during the taper to increase success rates 1, 7
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes 1
• Non-pharmacological approaches such as mindfulness and relaxation techniques can help manage withdrawal symptoms 1
• For sleep issues during temazepam tapering, consider sleep hygiene education rather than substituting another medication 3

Special Considerations

• If the patient has a history of withdrawal seizures, consider referral to a specialist 1
• For elderly patients or those with debilitating disease, consider an even more gradual taper 2
• Never abruptly discontinue either medication due to risk of withdrawal syndrome 1, 2, 5

Common Pitfalls to Avoid

• Tapering too quickly can precipitate withdrawal symptoms 1, 4
• Failing to provide adequate psychological support during the tapering process 1, 7
• Substituting one addictive medication for another 1, 4
• Underestimating the time needed for successful tapering - it may take several months 4, 6

The most recent evidence suggests that a masked tapering approach combined with behavioral interventions may improve benzodiazepine discontinuation rates compared to standard tapering alone 7, but the gradual reduction protocol described above remains the standard of care for safe discontinuation of these medications.