What is the safest method to taper a patient off benzodiazepines (benzos) when first-line therapies are ineffective or cause adverse effects?

From the Guidelines

To safely taper a patient off benzodiazepines, a gradual reduction of the benzodiazepine dose by 10-25% every 1-2 weeks is recommended, with adjustments based on patient tolerance, as evidenced by the most recent and highest quality study 1. When considering tapering benzodiazepines, it is essential to prioritize a gradual approach to minimize withdrawal symptoms and allow GABA receptors to readapt after being downregulated during chronic benzodiazepine use.

• The tapering schedule should be individualized, taking into account the patient's current dose, type of benzodiazepine, and medical history.
• For long-acting benzodiazepines like diazepam (Valium), a reduction of 1-2mg every 1-2 weeks can be considered, while for short-acting benzodiazepines like alprazolam (Xanax), switching to an equivalent dose of diazepam first may be beneficial due to its longer half-life.
• Adjunctive medications, such as pregabalin (150-600mg/day), gabapentin (900-3600mg/day), or clonidine (0.1-0.3mg twice daily), can help manage withdrawal symptoms, including anxiety and autonomic symptoms.
• Regular monitoring, with weekly or biweekly visits, is crucial to assess withdrawal symptoms and adjust the tapering schedule accordingly.
• Patient education about expected withdrawal symptoms and non-pharmacological coping strategies, such as cognitive behavioral therapy, relaxation techniques, and sleep hygiene, is vital for successful discontinuation, as supported by the EMPOWER trial 1.
• The goal of tapering should be to minimize withdrawal symptoms and improve the patient's quality of life, rather than rushing the process, as emphasized in the study by Mugunthan and colleagues 1.

From the FDA Drug Label

When necessary, immediate management of withdrawal symptoms requires re-institution of treatment at doses of alprazolam tablets sufficient to suppress symptoms. It is recommended that all patients on alprazolam tablets who require a dosage reduction be gradually tapered under close supervision The risk of withdrawal seizures may be increased at doses above 4 mg/day Patients, especially individuals with a history of seizures or epilepsy, should not be abruptly discontinued from any CNS depressant agent, including alprazolam tablets

The safest method to taper a patient off benzodiazepines (benzos) when first-line therapies are ineffective or cause adverse effects is to gradually taper the dose under close supervision. This approach helps minimize the risk of withdrawal seizures and other withdrawal symptoms. The rate of tapering should be individualized, and patients with a history of seizures or epilepsy should not be abruptly discontinued from any CNS depressant agent, including alprazolam tablets 2 2. Key considerations for tapering include:

• Gradual dose reduction
• Close supervision
• Individualized tapering rate
• Avoiding abrupt discontinuation, especially in patients with a history of seizures or epilepsy

From the Research

Tapering Methods

• Gradual tapering of benzodiazepines is a recommended approach, with studies suggesting a taper rate of 25% per week 3, 10% per day for high-dose withdrawal 4, or 0.25 mg per week for clonazepam 5.
• A fixed tapering regime or a symptom-triggered taper method can be used, with both methods showing similar effectiveness in reducing benzodiazepine dosage 6.

Adjunctive Therapies

• Carbamazepine may have promise as an adjunctive drug therapy for benzodiazepine withdrawal syndrome, particularly in patients receiving high daily dosages of benzodiazepines 3, 7.
• Antidepressants can be helpful in managing depression or panic during benzodiazepine withdrawal 7, 5.
• Psychological interventions, such as cognitive-behavioral therapy (CBT) and group therapy, can also be effective in supporting patients during benzodiazepine withdrawal 7.

Withdrawal Schedules

• The optimal rate of tapering benzodiazepines is not well established, but aiming for withdrawal in less than 6 months is recommended to avoid the withdrawal process becoming the focus of the patient's existence 7.
• Tapering schedules can vary from 4 weeks to several years, depending on the individual patient's needs and circumstances 7, 4, 5.

Monitoring and Support

• Primary-care practitioners play a crucial role in monitoring and supporting patients during benzodiazepine withdrawal, with simple interventions such as basic monitoring of repeat prescriptions and assessment by the doctor being effective in reducing benzodiazepine use 7.
• Pharmacists can also assist in monitoring benzodiazepine use and providing support to patients during withdrawal 7.