How to taper zopiclone (Zopiclone) 5 mg daily and diazepam (Diazepam) 10 mg daily in an elderly female patient?

Tapering Zopiclone and Diazepam in an Elderly Female Patient

In this elderly patient taking both zopiclone 5 mg and diazepam 10 mg daily, taper the diazepam first using a gradual reduction schedule of 10-25% of the current dose every 1-2 weeks, then address the zopiclone separately after benzodiazepine discontinuation is complete. 1

Critical Safety Principle: Which Medication to Taper First

When a patient is on both a benzodiazepine (diazepam) and a Z-drug (zopiclone), prioritize tapering the benzodiazepine first due to the higher risks associated with benzodiazepine withdrawal, including seizures and potentially fatal outcomes. 1, 2 This is particularly crucial in elderly patients who face elevated risks of cognitive impairment, falls, fractures, and loss of functional independence from benzodiazepines. 1

• Abrupt discontinuation of benzodiazepines can cause seizures and death, making gradual tapering absolutely essential. 1, 2
• The FDA explicitly warns that rapid dosage reduction or abrupt discontinuation can precipitate acute, life-threatening withdrawal reactions. 2

Diazepam Tapering Protocol (Address First)

Initial Assessment Before Starting Taper

• Screen for concurrent substance use disorders, psychiatric comorbidities, and any history of withdrawal seizures before initiating the taper. 1
• Patients with unstable psychiatric comorbidities, history of withdrawal seizures, or co-occurring substance use disorders should be referred to a specialist rather than managed in primary care. 1

Recommended Tapering Schedule for Diazepam 10 mg Daily

Use a percentage-based reduction of the current dose, not the original dose, to prevent disproportionately large reductions at the end of the taper. 1 For elderly patients, consider a more gradual taper with smaller dose reductions to minimize adverse effects. 1

Standard taper approach: 1

• Weeks 1-2: Reduce to 7.5 mg daily (25% reduction from current dose)
• Weeks 3-4: Reduce to 5.6-6 mg daily (20-25% reduction from current dose of 7.5 mg)
• Weeks 5-6: Reduce to 4.2-4.8 mg daily (20-25% reduction from current dose)
• Continue: Reduce by 10-25% of the current dose every 1-2 weeks until discontinuation

For patients on benzodiazepines for more than 1 year (likely in this case), consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks. 1 This more conservative approach may be particularly appropriate for elderly patients.

• 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
• The entire taper will likely take 6-12 months minimum, and possibly longer. 1

Monitoring During Diazepam Taper

Follow up at least monthly during the taper, with more frequent contact needed during difficult phases. 1

Monitor for withdrawal symptoms including: 1

• Anxiety, tremor, insomnia
• Sweating, tachycardia, headache
• Weakness, muscle aches, nausea
• Confusion or altered mental status
• Seizures (medical emergency)

Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1 Also monitor for mood changes and suicidal ideation. 1

Adjunctive Support During Diazepam Taper

Integrate cognitive behavioral therapy (CBT) during the taper, as this significantly increases success rates. 1, 3 Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement. 1, 3

Additional supportive measures include: 1

• Mindfulness and relaxation techniques
• Sleep hygiene education
• Exercise and fitness training

Consider pharmacological adjuvants cautiously: 1

• Gabapentin can help mitigate withdrawal symptoms (start 100-300 mg at bedtime or three times daily, increase by 100-300 mg every 1-7 days as tolerated, adjust for renal insufficiency). 1
• SSRIs (particularly paroxetine) may be used to manage underlying anxiety during tapering. 1
• Carbamazepine may help with withdrawal symptoms, though evidence is limited. 1, 4

Zopiclone Tapering Protocol (Address Second, After Diazepam Discontinuation)

Once diazepam has been successfully discontinued, address the zopiclone 5 mg daily. The current dose is already appropriate for elderly patients, as guidelines recommend 7.5-10 mg for geriatric insomniacs, with 5 mg being a conservative starting dose. 5

Zopiclone Discontinuation Approach

• For sleep issues during zopiclone tapering, prioritize sleep hygiene education rather than substituting another medication. 1
• Rapid dose decrease or abrupt discontinuance can produce withdrawal symptoms, including rebound insomnia. 6
• Consider reducing by 1.25 mg (25%) every 1-2 weeks: 5 mg → 3.75 mg → 2.5 mg → 1.25 mg → discontinue.

The American Academy of Sleep Medicine notes that benzodiazepine receptor agonists like zopiclone should be tapered gradually, with caution and downward dosage adjustment particularly advised in the elderly. 6

Critical Pitfalls to Avoid

• Never taper too quickly - research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1
• Never abandon the patient during the tapering process, as ongoing support is crucial for success. 1
• Never use abrupt discontinuation - this is equivalent to suddenly stopping antihypertensives or antihyperglycemics and can be life-threatening. 1, 2
• Avoid combining benzodiazepines with opioids if the patient is on any opioid medications, as this significantly increases risk of respiratory depression and death. 2

Special Considerations for Elderly Patients

• Elderly patients face particular risks from benzodiazepines including cognitive impairment, reduced mobility, unsafe driving, falls, fractures, and loss of functional independence. 1
• Long-acting agents like diazepam pose particular concerns due to sedation, cognitive impairment, and fall risk with injuries in this population. 1
• Use lower doses and more gradual tapers in elderly or frail patients. 6
• Advise the patient of increased overdose risk if they return to previous doses after tolerance is lost. 1

Expected Timeline

Realistic expectation: The complete process of tapering both medications will take a minimum of 6-12 months, and likely longer given the patient's age and dual medication regimen. 1 Patient agreement and interest in tapering is a key component of success. 1