What is the recommended protocol for tapering off Xanax (alprazolam)?

How to Taper Off Xanax (Alprazolam)

Reduce alprazolam by 25% every 1-2 weeks using a gradual tapering schedule, never stopping abruptly due to serious risks including seizures, which have been documented even after short-term use. 1

Critical Safety Warning

• Abrupt discontinuation of alprazolam can cause life-threatening seizures, even after relatively short-term use at standard doses (0.75-4 mg/day). 1
• Seizures occurred in 8 of 1,980 patients during discontinuation studies, with 5 cases clearly linked to abrupt dose reduction. 1
• Other severe withdrawal symptoms include hallucinations, delirium tremens, rebound anxiety, and in rare cases, death. 2, 3

Recommended Tapering Protocol

Standard Tapering Schedule

• Reduce the dose by 25% every 1-2 weeks as the primary evidence-based approach. 2, 3
• For patients on alprazolam for ≥1 year or at higher doses (>4 mg/day), consider an even slower taper of 10% per month. 2, 4
• Continue tapering until reaching very low doses before complete cessation—do not stop at "therapeutic minimum" doses. 5

Special Considerations for Alprazolam

• Alprazolam (a triazolobenzodiazepine) may require special handling: some experts recommend titrating at 0.5 mg every 2-3 days regardless of total dose. 6
• Patients on doses >4 mg/day have significantly more difficulty tapering to zero than those on lower doses. 1
• The short half-life of alprazolam makes withdrawal symptoms more intense compared to longer-acting benzodiazepines. 2

Practical Implementation Example

For a patient on 2 mg/day alprazolam (e.g., 1 mg twice daily):

• Week 1-2: Reduce to 1.5 mg/day (25% reduction = 0.5 mg decrease). 2, 3
• Week 3-4: Reduce to 1.125 mg/day (25% of current dose). 2, 3
• Week 5-6: Reduce to 0.84 mg/day (25% of current dose). 2, 3
• Continue this pattern until reaching very small doses before stopping completely. 5

Managing Withdrawal Symptoms

Expected Withdrawal Symptoms

• Physical symptoms: tremor, sweating, muscle cramps, insomnia, headache, heightened sensory perception, blurred vision. 1
• Psychological symptoms: anxiety, dysphoria, impaired concentration, irritability, anhedonia. 2, 1
• Gastrointestinal symptoms: diarrhea, nausea, appetite decrease. 1

Pharmacological Support

• α2-Agonists (clonidine or tizanidine) directly attenuate benzodiazepine withdrawal symptoms, though monitor for hypotension with clonidine. 2, 3
• Short-term adjuncts for specific symptoms: trazodone for insomnia, gabapentin for anxiety, mirtazapine for sleep and mood. 2
• Avoid loperamide in high doses due to arrhythmia risk despite its benefit for GI symptoms. 2

Non-Pharmacological Support

• Cognitive Behavioral Therapy (CBT) significantly increases tapering success rates and is particularly helpful for patients struggling with the taper. 2, 3
• Evidence-based psychotherapies should be offered for anxiety that emerges during tapering. 2

Monitoring and Follow-Up

• Monitor patients at least monthly during the tapering process. 4, 3
• If withdrawal symptoms become severe, temporarily return to the previous dose and resume tapering at a slower rate. 7
• Never abandon patients who struggle with tapering—consider pausing rather than discontinuing care. 4, 3
• Set realistic expectations about withdrawal symptoms and create contingency plans before starting. 3

Critical Pitfalls to Avoid

• Do not taper too quickly: the commonly recommended 2-4 week tapers show minimal benefit over abrupt discontinuation and are often not tolerated. 5
• Do not stop at "minimum therapeutic doses": taper to much lower doses to minimize withdrawal. 5
• If patient is also taking opioids, taper the benzodiazepine first due to greater risks of benzodiazepine withdrawal compared to opioid withdrawal. 2, 4
• Do not use straight-line tapers: each dose reduction should be a percentage of the current dose (e.g., 25% of 2 mg = 0.5 mg, then 25% of 1.5 mg = 0.375 mg), not equal absolute amounts. 7

Patient Education

• Educate patients that 71-93% of patients successfully taper off alprazolam in controlled studies, though success rates may be lower with higher doses and longer duration of use. 1
• Warn about increased overdose risk if returning to previous doses after successful tapering. 4
• Explain that withdrawal symptoms are expected, time-limited, and manageable with proper support. 2, 3