What is a safe taper schedule for a patient taking diazepam (alprazolam is not mentioned but diazepam is a benzodiazepine) 5 mg twice a day for 5.5 weeks on an outpatient basis?

Safe Diazepam Taper Schedule for 5.5 Weeks of Use

For a patient taking diazepam 5 mg twice daily (10 mg/day total) for 5.5 weeks, reduce the dose by 25% every 1-2 weeks over approximately 6-8 weeks on an outpatient basis. 1

Specific Tapering Protocol

Week 1-2: Reduce to 7.5 mg/day total

• Decrease from 10 mg/day to 7.5 mg/day (25% reduction) 1
• This can be achieved by taking 5 mg in morning and 2.5 mg in evening, or 2.5 mg three times daily 1

Week 3-4: Reduce to 5 mg/day total

• Decrease to 5 mg/day (approximately 33% of current dose) 1
• Take 2.5 mg twice daily 1

Week 5-6: Reduce to 2.5 mg/day total

• Decrease to 2.5 mg/day (50% of current dose) 1
• Take 2.5 mg once daily, preferably at bedtime 1

Week 7-8: Discontinue

• Reduce to 1.25 mg/day for several days if liquid formulation available, then discontinue 2
• If only tablets available, may alternate 2.5 mg every other day for final week before stopping 1

Critical Safety Considerations

Never abruptly discontinue benzodiazepines - abrupt cessation can cause seizures and death 1. This is as inappropriate as suddenly stopping antihypertensives or diabetes medications 1.

The taper rate must be guided by the patient's tolerance of withdrawal symptoms, not rigid adherence to schedule - pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1.

Monitoring Requirements

Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases 1. Monitor specifically for:

• Anxiety, tremor, insomnia, sweating, tachycardia 1
• Headache, weakness, muscle aches, nausea, confusion 1
• Mood changes and suicidal ideation 1
• Screen for depression, anxiety, and substance use disorders that may emerge 1

Adjunctive Strategies to Improve Success

Cognitive-behavioral therapy during the taper increases success rates and should be offered if available 1. This is particularly helpful for patients struggling with discontinuation 1.

Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement in the process 1.

Consider gabapentin as adjunctive therapy if withdrawal symptoms are problematic:

• Start with 100-300 mg at bedtime or three times daily 1
• Increase by 100-300 mg every 1-7 days as tolerated 1
• Titrate cautiously to avoid dizziness and sedation 1

Important Clinical Context

Since this patient has only been on diazepam for 5.5 weeks (less than 2 months), the withdrawal risk is substantially lower than for long-term users 3. The recommended 25% reduction every 1-2 weeks is appropriate for this duration of use 1. Patients on benzodiazepines for more than 1 year would require a slower taper of 10% per month 1, but this patient's shorter exposure allows for a more expeditious schedule.

Diazepam's long half-life is advantageous for tapering as it provides built-in smoothing of withdrawal symptoms compared to shorter-acting benzodiazepines 2. The availability of liquid diazepam formulation allows for precise dose reductions if needed 2.

When to Refer to Specialist

Refer if the patient has:

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Failed office-based tapering attempts 1

Advise the patient of increased overdose risk if they return to previous doses after tolerance is lost during or after the taper 1.