What is a recommended tapering schedule for a patient taking 4 mg of Ativan (lorazepam) per day?

Lorazepam Tapering from 4 mg Daily

For a patient taking 4 mg of lorazepam daily, reduce the dose by 25% every 1-2 weeks, which translates to decreasing by 1 mg every 1-2 weeks initially, then by 0.5 mg per week once you reach 2 mg daily, and finally by 0.25 mg per week when approaching discontinuation. 1

Recommended Tapering Schedule

The 25% reduction approach is the most widely supported method for benzodiazepine tapering:

• Weeks 1-2: Reduce from 4 mg to 3 mg daily (25% reduction) 1
• Weeks 3-4: Reduce from 3 mg to 2.25 mg daily (25% reduction) 1
• Weeks 5-6: Reduce from 2.25 mg to 1.5 mg daily 1
• Weeks 7-8: Reduce from 1.5 mg to 1 mg daily 1
• Weeks 9-10: Reduce from 1 mg to 0.5 mg daily 1
• Weeks 11-12: Reduce from 0.5 mg to 0.25 mg daily 1
• Weeks 13-14: Discontinue completely 1

This schedule results in a 3-4 month taper, which is appropriate for someone on chronic benzodiazepine therapy. 1

Alternative Faster Approach (If Clinically Appropriate)

For patients who have been on lorazepam for shorter durations, a more straightforward reduction may be tolerated:

• Decrease by 0.5 mg every 2 weeks until reaching 1 mg daily 2
• Then decrease by 0.25 mg per week until discontinuation 2

This approach, validated in a clonazepam discontinuation study, resulted in 68.9% of patients successfully tapering off within 4 months. 2

Critical Monitoring Points

Assess for withdrawal symptoms after each dose reduction before proceeding:

• Common withdrawal symptoms include anxiety, tremor, insomnia, sweating, tachycardia, headache, muscle aches, nausea, and weakness 2
• Severe withdrawal risks include rebound anxiety, hallucinations, seizures, and delirium tremens 1
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 1

Important Clinical Considerations

Cognitive-behavioral therapy (CBT) significantly increases tapering success rates and should be offered concurrently, particularly for patients struggling with the taper. 1

Never abruptly discontinue lorazepam as this can precipitate seizures and life-threatening withdrawal. 1, 3

The FDA label explicitly recommends gradual tapering to reduce withdrawal risk, though it does not specify exact schedules, leaving this to clinical judgment based on patient response. 3

Managing Withdrawal Symptoms During Taper

• For insomnia, consider short-term non-benzodiazepine sleep aids 1
• For anxiety, offer evidence-based psychotherapies (CBT) or non-benzodiazepine anxiolytics like buspirone 1
• Do not use anticholinergics like benztropine to manage symptoms 1

Special Populations

For elderly or debilitated patients, the taper should be even slower, potentially reducing by 10% of the current dose per month rather than every 1-2 weeks, as these patients are at higher risk for complications. 1, 3

Common Pitfalls to Avoid

• Tapering too quickly is the most common error—benzodiazepine withdrawal can be life-threatening unlike opioid withdrawal 1
• Not monitoring closely enough after each dose reduction 1
• Failing to address underlying anxiety with non-pharmacological interventions during the taper 1
• Using a rigid schedule without adjusting for individual patient tolerance 1