Alprazolam Taper Protocol
For a patient taking alprazolam 1 mg twice daily (2 mg total daily dose), reduce the dose by 0.25 mg every 1-2 weeks, which represents approximately a 12.5% reduction per step, continuing this gradual taper until complete discontinuation. 1
Initial Taper Strategy
- Start by reducing the total daily dose by 0.25 mg every 1-2 weeks, which is the FDA-recommended approach for alprazolam discontinuation 2
- This translates to either:
- Reducing one dose from 1 mg to 0.75 mg while maintaining the other at 1 mg, OR
- Reducing both doses proportionally (e.g., 0.875 mg twice daily)
- The 0.25 mg reduction every 1-2 weeks is specifically recommended for alprazolam regardless of whether this is considered low-dose or high-dose withdrawal 3
Critical Safety Considerations
Abrupt discontinuation must be avoided as benzodiazepine withdrawal can cause rebound anxiety, hallucinations, seizures, delirium tremens, and rarely death 1
- Alprazolam is particularly problematic for discontinuation compared to other benzodiazepines, with high rates of withdrawal symptoms and rebound phenomena 4
- The FDA explicitly warns that "abrupt discontinuation of treatment should be avoided" and emphasizes gradual dose reduction 2
Expected Timeline
- Total taper duration: approximately 8-16 weeks for a 2 mg daily dose using the 0.25 mg every 1-2 week schedule 2
- Some patients may require an even slower reduction rate, particularly if withdrawal symptoms emerge 2
- The taper schedule should be slowed or paused if significant withdrawal symptoms develop 1
Managing Withdrawal Symptoms
Adjuvant medications should be used liberally to prevent and treat withdrawal symptoms 1:
- Clonidine (start low, titrate carefully due to hypotension risk) or tizanidine (less effective but safer blood pressure profile) to directly attenuate withdrawal 1
- Lofexidine is FDA-approved specifically for opioid withdrawal but principles apply 1
- For anxiety, insomnia, and irritability: gabapentin, trazodone, mirtazapine, or tricyclic antidepressants for short-term use 1
- For gastrointestinal symptoms: loperamide (use cautiously, can be abused) 1
Withdrawal Symptom Profile
Common alprazolam withdrawal symptoms include 5, 6:
- Anxiety, tremor, shaking
- Nausea/vomiting
- Insomnia/nightmares
- Excessive sweating
- Tachycardia/palpitations
- Headache, muscle aches, weakness
- Unique to alprazolam: confusion, clouded sensorium, heightened sensory perception, paresthesias, blurred vision 6
Alternative Approach: Slower Taper
If the patient has been on alprazolam for prolonged periods or experiences significant withdrawal, consider an even more gradual approach:
- Reduce by 10% of the current dose every 1-2 weeks rather than fixed 0.25 mg decrements 1
- This means each new dose is 90% of the previous dose, not a straight-line reduction 1
- For a 2 mg daily dose: 2 mg → 1.8 mg → 1.62 mg → 1.46 mg, etc.
- This approach may take several months but reduces withdrawal severity 1
Monitoring and Support
- Close observation during taper is critical with clinician availability to treat symptoms and manage patient fears 1
- Reassess at each dose reduction for withdrawal symptoms, anxiety levels, and functional status 2
- Cognitive Behavioral Therapy (CBT) significantly increases tapering success rates and should be offered concurrently 1
- If benzodiazepines were prescribed for anxiety, evidence-based psychotherapy and/or antidepressants should be offered as alternatives 1
Important Caveats
- Do not abruptly stop or make large dose reductions except in extreme circumstances like confirmed diversion 1
- The final dose reductions (below 0.5 mg daily) may be the most difficult and require slower tapering 2, 6
- Rebound panic attacks occurred in 27% and withdrawal syndrome in 35% of patients in controlled studies, typically peaking at the end of taper 6
- Some patients may experience protracted withdrawal symptoms (dysphoria, insomnia, anhedonia) for months after complete discontinuation 1