Lorazepam Tapering for Alcohol Withdrawal
Start lorazepam at 6-12 mg/day divided into doses of 1-4 mg every 4-8 hours, then taper gradually following resolution of withdrawal symptoms. 1
Initial Dosing Strategy
Lorazepam is specifically recommended for patients with severe alcohol withdrawal syndrome (AWS), advanced age, recent head trauma, liver failure, respiratory failure, other serious medical comorbidities, or obesity. 1 This is because lorazepam undergoes direct glucuronidation without hepatic metabolism, making it safer in hepatic dysfunction compared to long-acting benzodiazepines like chlordiazepoxide or diazepam. 2
Starting Dose
- Begin with 6-12 mg/day total, divided into 1-4 mg doses every 4-8 hours 1
- The FDA label indicates the usual anxiety range is 2-6 mg/day, but alcohol withdrawal requires higher initial dosing 3
- For severe withdrawal, use the higher end of this range 1
Tapering Protocol
The taper should begin once withdrawal symptoms resolve, with gradual dose reduction to minimize withdrawal reactions. 1, 3
Structured Taper Approach
- Fixed-dose tapering regimen: Start at 6-8 mg/day on day 1, tapering to 2 mg/day by day 4-5 4, 5
- Symptom-triggered approach is superior: This method uses significantly less total medication (mean 9.5 mg vs 19.9 mg) over a shorter duration (47.8 hours vs 146 hours) compared to fixed-dose regimens, with equal safety 6
- Increase evening doses before daytime doses when higher dosing is needed 3
- If withdrawal reactions develop during taper, pause the taper or increase back to the previous dose level, then decrease more slowly 3
Monitoring Requirements
Use CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) scores to guide treatment intensity, though it should not be used alone for diagnosis. 1, 2
Assessment Parameters
- CIWA-Ar score >8 indicates moderate withdrawal; ≥15 indicates severe withdrawal 2
- Monitor vital signs, mental status, and withdrawal symptoms regularly 2
- Symptom-triggered regimens prevent medication accumulation and are preferred over fixed schedules 2, 6
Critical Adjunctive Treatment
Thiamine 100-300 mg/day must be given to ALL patients with alcohol withdrawal syndrome before any glucose-containing fluids to prevent Wernicke encephalopathy. 1, 2, 7 This is non-negotiable as IV glucose can precipitate acute thiamine deficiency. 2, 7
Additional Supportive Care
- Ensure adequate hydration and electrolyte replacement, especially magnesium 2
- Continue thiamine for 2-3 months following resolution of withdrawal symptoms 1
Duration Considerations
Avoid benzodiazepine use beyond 10-14 days due to abuse potential. 2 The typical alcohol withdrawal taper is completed within 4-8 days. 4, 5
Common Pitfalls
- Do not use lorazepam as first-line in uncomplicated withdrawal with normal liver function: Long-acting benzodiazepines (chlordiazepoxide, diazepam) provide better seizure protection in standard cases 1
- Lorazepam-treated patients may experience rebound withdrawal symptoms post-treatment: This occurred significantly more with lorazepam than carbamazepine in one study 4
- 20% of lorazepam-treated patients experienced dizziness, motor incoordination, or ataxia without recognizing their impairment 4
- Abrupt discontinuation increases seizure and delirium tremens risk: Always use gradual tapering 3
Inpatient vs Outpatient Decision
Admit patients with serious complications (delirium, seizures), significant medical/psychiatric comorbidities, history of withdrawal seizures or delirium tremens, high levels of recent drinking, or failed outpatient treatment. 1, 2