What is the recommended taper schedule for a patient on lorazepam (Ativan)?

Lorazepam Tapering Protocol

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

Critical Safety Principles

Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually—abrupt discontinuation can cause seizures and death. 2, 1, 3

• If a patient is taking both opioids and benzodiazepines, taper the benzodiazepine first due to higher withdrawal risks 2, 1
• Never abruptly discontinue lorazepam, as this approach is as inappropriate as suddenly stopping antihypertensives or antihyperglycemics 2

Standard Tapering Schedule

For Short-to-Intermediate Term Use (< 1 year)

• Reduce by 10% of the most recent dose every 2-4 weeks 1
• The FDA label recommends using a gradual taper but does not specify exact percentages—defer to guideline recommendations 3

For Long-Term Use (≥ 1 year)

• Reduce by 10% of the most recent dose per month or slower 2, 1
• Some patients may tolerate 10% per week initially, but slower tapers (10% per month) are better tolerated for long-term users 2

Key Tapering Principle

• Always calculate reductions as a percentage of the current dose, not the original dose—this prevents disproportionately large final reductions 2
• Example: If starting at 2 mg/day, first reduction to 1.8 mg (10% of 2 mg), then to 1.62 mg (10% of 1.8 mg), continuing this pattern 2

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
• Assess for concurrent substance use disorders, psychiatric comorbidities, and history of withdrawal seizures 2

During the Taper

• The taper rate must be determined by the patient's tolerance, not a rigid schedule—pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 2
• If withdrawal reactions develop, pause the taper or increase the dosage back to the previous level, then decrease more slowly 3
• Monitor for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion 4, 5, 6
• Follow up at least monthly during the taper, with more frequent contact during difficult phases 2
• Screen for depression, anxiety, suicidal ideation, and emerging substance use disorders 2

Adjunctive Strategies to Improve Success

Pharmacological Support

• Gabapentin can help mitigate withdrawal symptoms: start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated (adjust for renal insufficiency) 2, 1
• For sleep issues, prioritize sleep hygiene education rather than substituting another sedative 2
• Consider SSRIs (like paroxetine) for managing underlying anxiety during tapering 2
• Carbamazepine may help with withdrawal symptoms but can affect alprazolam metabolism 2

Non-Pharmacological Support

• Cognitive behavioral therapy (CBT) during the taper increases success rates and should be incorporated whenever possible 2, 1
• Incorporate mindfulness, relaxation techniques, and psychotherapy 2
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 2, 1

When to Refer to a Specialist

Refer patients with any of the following: 2, 1

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

Special Populations

Elderly or Debilitated Patients

• Consider a more gradual taper with smaller dose reductions to minimize adverse effects 1, 3
• The FDA recommends initial dosing of 1-2 mg/day in divided doses for elderly patients 3

Patients on High Doses

• Those taking higher dosages are at increased risk of withdrawal reactions and require slower tapers 3

Pregnant Patients

• Do not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 4

Common Pitfalls to Avoid

• Do not reduce by a fixed amount each time—this creates disproportionately large reductions at lower doses 2
• Do not rush the taper based on a predetermined timeline—let patient tolerance guide the pace 2
• Do not ignore mild withdrawal symptoms—they signal the need to slow down 2
• Warn patients about increased overdose risk if they return to previous doses after tolerance is lost 2
• Avoid prescribing opioids and benzodiazepines simultaneously whenever possible due to increased risk of respiratory depression and death 2, 3

Monitoring Requirements

Throughout the taper, monitor for: 2

• Withdrawal symptoms (anxiety, tremor, insomnia, autonomic instability)
• Mood changes and suicidal ideation
• Emerging depression, anxiety, or substance use disorders
• Vital signs if symptoms suggest autonomic instability