Tapering Alprazolam (Xanax) 0.5mg Twice Daily
For a patient on alprazolam 0.5mg twice daily (1mg total daily dose) for long-term use, reduce the dose by 0.25mg (25% of total daily dose) every 1-2 weeks, targeting an 8-week taper to complete discontinuation, while monitoring closely for withdrawal symptoms and providing adjunctive support. 1
Recommended Tapering Schedule
The most practical approach follows this specific timeline 1:
- Weeks 1-2: 0.5mg morning + 0.25mg evening = 0.75mg daily
- Weeks 3-4: 0.25mg morning + 0.25mg evening = 0.5mg daily
- Weeks 5-6: 0.25mg morning + 0mg evening = 0.25mg daily
- Weeks 7-8: 0mg morning + 0mg evening = discontinuation
This schedule represents a 25% reduction of the total daily dose every 1-2 weeks, which aligns with CDC recommendations for gradual benzodiazepine tapering 1. The FDA explicitly warns against abrupt discontinuation due to serious withdrawal risks including seizures 2.
Critical Safety Considerations
Never abruptly discontinue alprazolam. The FDA label specifically states that withdrawal symptoms including seizures have been reported after only brief therapy at doses within the recommended range (0.75-4mg/day), and that patients should not be abruptly discontinued from any CNS depressant 2. The risk of withdrawal seizures increases at doses above 4mg/day, but seizures can occur at any dose with abrupt cessation 2.
Withdrawal Symptoms to Monitor
Expect and monitor for these withdrawal manifestations 2:
- Common symptoms: Insomnia (29.5%), anxiety (19.2%), lightheadedness (19.3%), fatigue (18.4%), irritability (10.5%)
- Neurological: Abnormal involuntary movements (17.3%), muscle twitching, paresthesias, tremors
- Severe symptoms: Seizures, confusion, heightened sensory perception, muscle cramps
- Gastrointestinal: Nausea/vomiting (16.5%), diarrhea (13.6%), decreased appetite
- Cardiovascular: Tachycardia (12.2%)
The time course matters: withdrawal symptoms typically appear toward the end of taper or shortly after discontinuation and will decrease with time, distinguishing them from relapse of the underlying anxiety disorder 2.
When to Slow or Pause the Taper
If significant withdrawal symptoms emerge, pause or slow the taper immediately. 3 The taper rate must be determined by patient tolerance, not rigid adherence to schedule 3. Some patients may need to extend beyond the 8-week timeline, particularly those who have been on alprazolam for more than 1 year 3.
Research shows that slower tapers are more successful than rapid discontinuation. Studies demonstrate that tapers over months down to doses much lower than therapeutic minimums show greater success in reducing withdrawal symptoms compared to the traditional 2-4 week tapers 4.
Adjunctive Pharmacological Support
Gabapentin as Primary Adjunct
Consider gabapentin to mitigate withdrawal symptoms, starting at 100-300mg at bedtime or three times daily, increasing by 100-300mg every 1-7 days as tolerated 3, 5. Effective doses typically range 900-3600mg/day in divided doses 5. Gabapentin works by binding to N-type voltage-gated calcium channels and can help manage anxiety, insomnia, and irritability during discontinuation 5.
Important caveat: Common side effects include somnolence, dizziness, and mental clouding, which can be problematic especially in older adults 5. Patients with renal impairment require lower starting doses and careful titration 5.
Alternative Adjunctive Medications
Other options for managing specific withdrawal symptoms include 1, 5:
- Buspirone: For anxiety and insomnia management
- Clonidine, tizanidine, or lofexidine: For physical withdrawal symptoms (autonomic hyperactivity)
Avoid concurrent use of other CNS depressants during the taper when possible 5.
Non-Pharmacological Interventions
Cognitive-behavioral therapy (CBT) during taper significantly increases success rates. 3 Weekly 90-120 minute group sessions during the taper period have demonstrated feasibility and effectiveness 6. Patient education about benzodiazepine risks and withdrawal expectations improves outcomes 3.
Additional supportive strategies include 1:
- Relaxation techniques
- Physical activity
- Addressing underlying anxiety with non-pharmacological approaches
Monitoring Protocol
Weekly follow-up is recommended during the taper to monitor for 3:
- Withdrawal symptoms using a standardized scale
- Mood changes and suicidal ideation
- Functional status
- Signs of relapse versus withdrawal
The distinction between withdrawal and relapse is critical: withdrawal symptoms are typically new, appear toward the end of taper, and decrease with time, whereas relapse symptoms resemble pre-treatment anxiety and persist 2.
Special Populations Requiring Modified Approach
High-Risk Patients Requiring Specialist Referral
Do not attempt primary care tapering in these situations 3:
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Pregnant patients (risk of spontaneous abortion and premature labor)
- Patients requiring more than 1 year of use may need 10% monthly reductions rather than weekly 3
Elderly Patients
Require more gradual tapers with smaller dose reductions due to increased sensitivity to both benzodiazepines and withdrawal symptoms 3.
Common Pitfalls to Avoid
Tapering too rapidly: The traditional recommendation of 0.5mg every 3 days 2 is often too aggressive and leads to high failure rates. The 25% every 1-2 weeks approach is better tolerated 1.
Ignoring underlying anxiety disorder: Simply removing the medication without addressing the original indication leads to poor outcomes 6. Concurrent treatment of the underlying anxiety disorder is essential 1.
Mistaking withdrawal for relapse: This leads to unnecessary reinstitution of medication 2. Use the time course and symptom pattern to distinguish between the two.
Failing to warn about overdose risk: If patients return to previous doses after tolerance is lost, they face increased overdose risk 3.
Not addressing concurrent substance use: Patients with history of alcohol or drug abuse are at higher risk for difficulty tapering and require closer monitoring 2.
Expected Outcomes
Research demonstrates that standardized advice from the physician combined with a structured tapering schedule achieves discontinuation in approximately 45% of patients at 12 months, compared to only 9% with routine care 7. For every three interventions, one patient achieves complete withdrawal 7.
Reassure patients that most experience stable or improved anxiety after successful taper, as benzodiazepines can paradoxically worsen anxiety with long-term use through tolerance and rebound effects 6.