What can be done to manage tinnitus (ringing in the ears) during benzodiazepine (benzo) taper?

Managing Tinnitus During Benzodiazepine Taper

Tinnitus during benzodiazepine tapering is a recognized withdrawal symptom that requires slowing or pausing the taper until symptoms stabilize, rather than attempting to treat the tinnitus itself. 1, 2

Understanding Tinnitus as a Withdrawal Symptom

Tinnitus is a documented but rare complication of benzodiazepine withdrawal that can be debilitating and long-lasting. 2 This symptom can emerge even during gradual tapers—case reports document tinnitus developing within 7 weeks of reducing clonazepam to 50% of the original dose. 2 The persistence of tinnitus may prevent further dose reductions and requires individualized taper adjustments. 2

Immediate Management Strategy

Modify the Taper Protocol

• Pause the current taper immediately when tinnitus emerges and maintain the current benzodiazepine dose until symptoms stabilize. 1, 2
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule—pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1
• Once tinnitus resolves or becomes tolerable, resume tapering at a slower rate than previously attempted. 1

Adjust Taper Speed

• Slow the reduction schedule to 10% of the current dose per month (not the original dose) for patients experiencing withdrawal symptoms, rather than the standard 25% every 1-2 weeks. 1
• For patients on benzodiazepines for more than 1 year who develop withdrawal symptoms, extending the taper to 10% per month is specifically recommended. 1
• Each reduction should be calculated as a percentage of the current dose to prevent disproportionately large final reductions. 1

Adjunctive Pharmacological Support

Consider Gabapentin

• Gabapentin can help mitigate withdrawal symptoms during benzodiazepine tapering, including potentially reducing the severity of tinnitus as a withdrawal symptom. 1
• Start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated. 1
• Titrate cautiously to avoid dose-dependent dizziness and sedation, and adjust dosing in patients with renal insufficiency. 1

Alternative Adjunctive Medications

• Carbamazepine can help mitigate benzodiazepine withdrawal symptoms, though it may affect alprazolam metabolism. 1
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1
• SSRIs like paroxetine may be used to manage underlying anxiety during tapering. 1

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) during the taper increases success rates and should be incorporated for patients struggling with benzodiazepine discontinuation. 1
• Psychological or supportive therapies including mindfulness and relaxation techniques should be integrated into the management plan. 1
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement in the tapering process. 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact needed during difficult phases when symptoms like tinnitus emerge. 1
• Monitor specifically for withdrawal symptoms including anxiety, depression, seizures, and altered mental status in addition to tinnitus. 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1

When to Refer to a Specialist

• Refer patients to a specialist if office-based tapering has been unsuccessful or if tinnitus persists despite taper modifications. 1
• Patients with co-occurring substance use disorders require specialist involvement. 1
• Those with unstable psychiatric comorbidities need specialist management. 1

Critical Safety Considerations

• Never abruptly discontinue benzodiazepines, as this can cause seizures and death—benzodiazepine withdrawal carries greater risks than opioid withdrawal. 1, 3
• If the patient is also taking opioids requiring discontinuation, taper the benzodiazepines first due to the higher risks associated with benzodiazepine withdrawal. 1, 3
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1

What NOT to Do

• Do not attempt to treat the tinnitus directly with medications (such as intratympanic steroids or other tinnitus-specific treatments) while it is occurring as a withdrawal symptom—the primary intervention is taper modification. 2
• Do not continue the taper at the same rate if tinnitus develops, as this indicates the reduction schedule is too aggressive for that patient. 1, 2
• Do not use benzodiazepines themselves to treat tinnitus in this context, as this would be counterproductive to the tapering goal. 4, 5