Diazepam Tapering from 10mg Twice Daily
For a patient on diazepam 20mg daily (10mg twice daily), reduce the dose by 25% of the current dose every 1-2 weeks, which translates to decreasing by 5mg every 1-2 weeks initially, then slowing the taper as you approach lower doses. 1
Initial Tapering Schedule
Week 1-2: Reduce from 20mg/day to 15mg/day (25% reduction) 1
- This can be achieved by taking 10mg in morning and 5mg in evening, or 7.5mg twice daily
Week 3-4: Reduce to 11-12mg/day (20-25% of current 15mg dose) 1
- Example: 7.5mg in morning and 4mg in evening
Week 5-6: Reduce to approximately 8-9mg/day (continuing 20-25% reductions of current dose) 1
Continue this pattern: Reduce by 10-25% of the current dose (not the original dose) every 1-2 weeks 1
Critical Tapering Principles
The reduction must be based on a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions that can trigger severe withdrawal. 1 For example, when you reach 4mg/day, the next reduction should be 0.8-1mg (20-25% of 4mg), not another 5mg reduction.
The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 1 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1
Extended Tapering for Long-Term Users
If this patient has been on benzodiazepines for more than 1 year, consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks. 1 This slower approach is better tolerated and reduces withdrawal severity. 2
Monitoring Withdrawal Symptoms
Monitor closely for withdrawal symptoms including: 1
- Anxiety, tremor, insomnia
- Sweating, tachycardia, palpitations
- Headache, weakness, muscle aches
- Nausea, confusion
Benzodiazepine withdrawal carries greater risks than opioid withdrawal and should always be conducted gradually. 1 Abrupt discontinuation can lead to seizures and, rarely, death. 1
Follow-Up Requirements
Follow up at least monthly during the taper, with more frequent contact needed during difficult phases. 1 Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
Warn the patient about increased overdose risk if they return to previous doses after tolerance is lost. 1
Adjunctive Support Strategies
Consider adding: 1
- Cognitive behavioral therapy (CBT) during the taper, which increases success rates
- Gabapentin starting at 100-300mg at bedtime or three times daily, titrated by 100-300mg every 1-7 days as tolerated to help mitigate withdrawal symptoms 1
- Carbamazepine or pregabalin as alternatives for managing withdrawal symptoms 1
Special Circumstances Requiring Specialist Referral
Refer to a specialist if the patient has: 1
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders
- Failed office-based tapering attempts
If the patient is also taking opioids, taper the benzodiazepine first due to the higher risks associated with benzodiazepine withdrawal. 1
Final Dosing Strategy
Once you reach the smallest available dose (typically 2mg), extend the interval between doses rather than continuing to reduce the dose. 2 For example, take 2mg every other day, then twice weekly, then discontinue completely. 3