How do you taper off 1.5 mg lorazepam (Ativan) while starting Belsomra (suvorexant)?

Tapering Lorazepam While Starting Belsomra

Reduce lorazepam by 10% of the current dose every 2-4 weeks while starting Belsomra at bedtime, but never abruptly discontinue the benzodiazepine as this can cause life-threatening seizures and withdrawal. 1, 2

Critical Safety Principles

• Never abruptly stop lorazepam - sudden discontinuation can precipitate seizures, severe withdrawal reactions, and rarely death, making gradual tapering mandatory 2
• Lorazepam is specifically identified as one of the benzodiazepines more likely to induce withdrawal symptoms, requiring extra caution during tapering 3
• The FDA explicitly requires gradual tapering to reduce withdrawal risk, and if withdrawal symptoms develop, pause the taper or return to the previous well-tolerated dose 2

Starting Belsomra During the Taper

• Begin Belsomra (suvorexant) at the standard dose for insomnia while maintaining the current lorazepam dose initially to avoid destabilizing sleep 4
• Be aware that potential pharmacokinetic interactions may occur between suvorexant and benzodiazepines, though the clinical significance is uncertain 4
• Suvorexant provides moderate benefits (users fall asleep 6 minutes faster and sleep 16 minutes longer than placebo after 3 months), so set realistic expectations 4
• Common side effects of suvorexant include next-day somnolence, fatigue, dry mouth, headache, and dizziness - monitor for additive sedation when combined with lorazepam 5, 4

Specific Tapering Protocol for 1.5 mg Lorazepam

Week 1-2: Reduce to 1.35 mg daily (10% reduction from 1.5 mg) 1

• This represents a 0.15 mg decrease
• Maintain this dose for at least 2 weeks before the next reduction

Week 3-4: Reduce to approximately 1.2 mg daily (10% reduction from 1.35 mg) 1

• Each subsequent reduction should be 10% of the most recent dose, not the original dose 1

Continue pattern: Reduce by 10% of the current dose every 2-4 weeks 1

• For long-term users (≥1 year), consider slowing to 10% reductions per month rather than every 2-4 weeks 1
• The entire taper may take several months to complete 1

Practical Dosing Challenges

• Lorazepam tablets typically come in 0.5 mg, 1 mg, and 2 mg strengths, making precise 10% reductions difficult 2
• Consider using lorazepam oral concentrate (2 mg/mL) with the calibrated dropper for more precise dose adjustments during the final stages of tapering 2
• Alternatively, work with a compounding pharmacy to create custom doses for the taper

Managing Withdrawal Symptoms

• Monitor for withdrawal symptoms after each dose reduction: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and irritability 1, 6
• If withdrawal symptoms become severe, return to the previous well-tolerated dose and slow the taper further (consider 5% reductions or extend intervals to 4-6 weeks) 1, 2
• Never abandon the patient if they struggle with the taper - consider pausing at a stable dose rather than pushing forward 1

Adjunctive Strategies to Support the Taper

• Cognitive-behavioral therapy for insomnia (CBT-I) during the taper significantly increases success rates and should be strongly considered 7, 6
• Consider gabapentin as an adjuvant: start with 100-300 mg at bedtime or three times daily, titrating by 100-300 mg every 1-7 days as tolerated (adjust for renal insufficiency) 6
• Other adjunctive medications for specific withdrawal symptoms include: 6
  • Clonidine or tizanidine for autonomic symptoms (sweating, tachycardia)
  • Trazodone for persistent insomnia
  • SSRIs like paroxetine for underlying anxiety (though start early as they take weeks to work)
• Incorporate non-pharmacological approaches: sleep hygiene education, relaxation techniques, mindfulness, and psychotherapy 7, 6

Monitoring Requirements

• Schedule follow-up appointments at least monthly during the taper, with more frequent contact during difficult phases 1, 6
• At each visit, assess for: 1, 6
  • Withdrawal symptoms
  • Mood changes and suicidal ideation
  • Sleep quality and insomnia severity
  • Depression, anxiety, and substance use disorders that may emerge
  • Next-day sedation from Belsomra

Special Considerations

• For patients who have used lorazepam for ≥1 year, the taper may require several months to over a year to complete - prioritize durability over speed 1
• Some patients may benefit from maintenance at a reduced dose rather than complete discontinuation 1
• If the patient has a history of seizures, involve a neurologist and taper even more slowly 1
• Pregnant patients should not taper without specialist consultation as benzodiazepine withdrawal can cause spontaneous abortion and premature labor 1, 6
• Elderly or debilitated patients may require slower tapers with smaller dose reductions to minimize adverse effects 6, 2

Common Pitfalls to Avoid

• Do not taper too quickly - reductions faster than 10% every 2-4 weeks increase withdrawal risk 1
• Do not use fixed timelines - the taper must be adjusted based on individual response, not a predetermined schedule 1
• Do not calculate percentage reductions from the original dose - each reduction should be a percentage of the previous dose to avoid disproportionately large final reductions 6
• Do not substitute sleep hygiene advice alone for pharmacological support during difficult withdrawal phases 7
• Warn patients about increased overdose risk if they return to previous lorazepam doses after tolerance is lost 6

When to Refer to a Specialist

• History of withdrawal seizures from prior benzodiazepine discontinuation attempts 6
• Co-occurring substance use disorders requiring medication-assisted treatment 6
• Unstable psychiatric comorbidities (severe depression, psychosis, suicidal ideation) 6
• Multiple failed office-based tapering attempts 6
• Pregnancy or planning pregnancy 1, 6