What is a suitable tapering schedule for a patient taking Valium (diazepam) 5 mg twice a day?

Valium (Diazepam) 5 mg Twice Daily Tapering Schedule

For a patient taking diazepam 5 mg twice daily (10 mg/day total), reduce the dose by 25% every 1-2 weeks, which translates to decreasing by 2.5 mg every 1-2 weeks until reaching 1 mg/day, then taper by 0.25 mg per week until discontinuation. 1

Recommended Tapering Protocol

Standard Taper Schedule

• Week 1-2: Reduce to 7.5 mg/day (5 mg morning, 2.5 mg evening OR 2.5 mg morning, 5 mg evening) 1
• Week 3-4: Reduce to 5 mg/day (2.5 mg twice daily) 1
• Week 5-6: Reduce to 2.5 mg/day (2.5 mg once daily) 1
• Week 7: Reduce to 2 mg/day 2
• Week 8: Reduce to 1.5 mg/day 2
• Week 9: Reduce to 1 mg/day 2
• Week 10: Reduce to 0.75 mg/day 2
• Week 11: Reduce to 0.5 mg/day 2
• Week 12: Reduce to 0.25 mg/day 2
• Week 13: Discontinue 2

Alternative Slower Taper for Long-Term Users

For patients who have been on diazepam for more than 1 year, consider an even slower reduction of 10% of the original dose per month (1 mg per month), which may be better tolerated. 1

Critical Safety Considerations

Abrupt Discontinuation Risks

Never abruptly discontinue diazepam—this can cause life-threatening withdrawal including seizures, delirium tremens, hallucinations, and in rare cases, death. 1, 3

Concurrent Opioid Use

If the patient is taking opioids concurrently with diazepam, taper the opioids first due to the quadrupled risk of fatal respiratory depression from combined use. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal, making it safer to address opioid tapering initially. 1

Monitoring During Taper

Withdrawal Symptoms to Monitor

Assess for these symptoms after each dose reduction before proceeding: 1, 2

• Autonomic: Anxiety, sweating, tachycardia/palpitations, tremor
• Neurological: Insomnia/nightmares, headache, seizures (rare but serious)
• Gastrointestinal: Nausea/vomiting
• Musculoskeletal: Muscle aches, weakness
• Psychiatric: Rebound anxiety, irritability, agitation

Follow-Up Frequency

Monitor patients at least monthly during the tapering process, with more frequent visits if withdrawal symptoms emerge. 4

Managing Withdrawal Symptoms

If Withdrawal Symptoms Occur

• Mild symptoms: Provide reassurance that symptoms are typically transient and self-limiting 5
• Moderate to severe symptoms: Return to the previous well-tolerated dose and slow the taper further (extend time between reductions to 3-4 weeks instead of 1-2 weeks) 1, 3
• Pause the taper if needed and restart when the patient is ready 1, 6

Adjunctive Symptom Management

• For autonomic symptoms (sweating, tachycardia): Consider α2-adrenergic agonists like clonidine 4
• For insomnia: Short-term non-benzodiazepine sleep aids 4
• For muscle aches: Acetaminophen or NSAIDs 4
• Psychological support: Cognitive behavioral therapy (CBT) significantly increases tapering success rates 1

Special Populations

Elderly or Debilitated Patients

The FDA label recommends starting with lower doses (2-2.5 mg once or twice daily initially) for elderly patients. 3 Apply this same caution to tapering—use the slower 10% per month reduction schedule. 1

Patients with Seizure History

These patients require particularly careful monitoring during the taper, as abrupt withdrawal can precipitate seizures. 4, 3 Consider even slower tapering (10% per month) and close neurological monitoring. 1

Common Pitfalls to Avoid

• Tapering too quickly: This is the most common error and increases risk of severe withdrawal symptoms and treatment failure 4
• Setting arbitrary time limits: The taper should be guided by patient tolerance, not calendar deadlines 7, 4
• Mistaking withdrawal for relapse: Withdrawal symptoms can mimic the original anxiety disorder; distinguish by timing (withdrawal occurs within days of dose reduction) 5
• Stopping at therapeutic minimum doses: Taper to doses much lower than minimum therapeutic doses (down to 0.25 mg) before complete discontinuation 8, 2

Alternative Dosing Strategy for Final Stages

Once reaching 1 mg/day, instead of further dose reductions, you can extend the interval between doses: 6

• 1 mg every other day for 1-2 weeks
• 1 mg every third day for 1-2 weeks
• Then discontinue

When to Consider Inpatient Taper

Consider hospitalization for tapering if: 1

• Significant coexisting psychiatric illness
• Substance use disorder
• Unstable medical conditions (e.g., cardiac disease)
• History of severe withdrawal symptoms or seizures
• Lack of social support for outpatient monitoring