What is the recommended approach for tapering off lorazepam (Ativan)?

Lorazepam Tapering Protocol

For lorazepam tapering, reduce the dose by 10% of the most recent dose every 2-4 weeks, with slower reductions (10% per month or less) for patients on long-term therapy (≥1 year). 1

Critical Safety Principles

• Never abruptly discontinue lorazepam except in cases of confirmed diversion or serious medical toxicity, as abrupt cessation can precipitate life-threatening withdrawal reactions including seizures and death. 1, 2
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 3
• If the patient is taking both opioids and benzodiazepines, taper the benzodiazepine first due to higher withdrawal risks. 3

Standard Tapering Schedule

For Standard Cases (Short-to-Intermediate Term Use)

• Reduce by 10% of the most recent dose every 2-4 weeks. 1
• For example, if taking 2 mg daily, reduce by 0.2 mg every 2-4 weeks. 1

For Long-Term Users (≥1 Year)

• Use slower reductions of 10% per month or less. 1
• Patients with prolonged use require tapers extending over months. 4, 3
• The guideline recommends reductions of 25% of the initial dose every 1-2 weeks as an alternative approach, though this may be too rapid for some patients. 3

Managing the Taper Process

Before Starting

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

During the Taper

• Monitor for withdrawal symptoms after each dose reduction before proceeding to the next step. 1
• Watch specifically for increased anxiety, depression, seizures, and altered mental status. 4, 3
• If withdrawal symptoms become severe, return to the previous well-tolerated dose and slow the taper further. 1
• Monitor patients at least monthly during the tapering process. 1

Common Withdrawal Symptoms to Anticipate

• Increased anxiety, insomnia, tremor, sweating, tachycardia, headache, muscle aches, and weakness. 5
• More severe symptoms can include confusion, heightened sensory perception, paresthesias, and seizures. 6

Adjunctive Strategies

Pharmacological Support

• Gabapentin can help mitigate withdrawal symptoms during tapering. Start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated. 3
• Carbamazepine may help with withdrawal symptoms, though it can affect metabolism of some benzodiazepines. 3
• Pregabalin has shown potential benefit in facilitating tapering. 3
• SSRIs (particularly paroxetine) may manage underlying anxiety during tapering. 3
• Clonidine (an α2-adrenergic agonist) can be considered for autonomic withdrawal symptoms. 1

Non-Pharmacological Approaches

• Cognitive behavioral therapy (CBT) during the taper increases success rates and should be incorporated. 3, 1
• Include mindfulness, relaxation techniques, and psychotherapy. 3
• Encourage regular exercise. 1
• Provide patient education about benzodiazepine risks and benefits of tapering to improve outcomes. 3

When to Refer to a Specialist

Refer rather than attempt primary care tapering if the patient has: 4, 3

• History of withdrawal seizures
• Other significant medical comorbidities
• Co-occurring substance use disorders
• Unreliable history about amount being taken
• Poor motivation or adherence
• Failed office-based tapering attempts

Critical Pitfalls to Avoid

• Do not taper too quickly (faster than 10% reduction every 2-4 weeks). 1
• Do not set arbitrary time limits for completing the taper. 1
• Do not abandon patients who are struggling with the taper; consider pausing the reduction rather than discontinuing care. 1
• Do not prescribe opioids and benzodiazepines simultaneously whenever possible due to increased risk of respiratory depression and death. 3, 2

Special Populations

Elderly Patients

• Consider a more gradual taper with smaller dose reductions to minimize adverse effects. 3

Patients with Co-occurring Opioid Use

• If both medications need discontinuation, reduce benzodiazepines first due to higher withdrawal risks. 3
• If opioids must be continued, prescribe the lowest effective dosages and monitor closely for respiratory depression. 2