Diazepam Tapering Protocol
For diazepam tapering, reduce the dose by 10-25% of the current dose (not the original dose) every 1-2 weeks, slowing to 10% per month for patients on benzodiazepines longer than 1 year, with the understanding that the taper will likely take 6-12 months minimum and possibly much longer. 1
Core Tapering Principles
The reduction must be calculated as a percentage of the current dose, not the original starting dose. 1 This is a critical distinction that prevents disproportionately large reductions as you approach lower doses. For example, if a patient starts at 20 mg/day:
- Week 1-2: Reduce to 15 mg/day (25% reduction of current 20 mg dose) 1
- Week 3-4: Reduce to 11-12 mg/day (20-25% of current 15 mg dose) 1
- Continue reducing by 10-25% of the current dose every 1-2 weeks 1
For patients who have been taking benzodiazepines for more than 1 year, extend the taper to 10% per month rather than 10-25% every 1-2 weeks. 1 Long-term users require slower tapers because they have developed more significant physiological dependence. 1
Determining Your Taper Rate
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 This is not a failure—maintaining patient comfort and function is paramount. 1
If withdrawal symptoms become severe, return to the previous well-tolerated dose and slow the taper further. 1 Never push through intolerable symptoms, as this leads to taper failure and patient abandonment of the process. 1
Monitoring Requirements
Follow up at least monthly during the taper, with more frequent contact needed during difficult phases. 1 At each visit, monitor for:
- Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion 1
- Mood changes and suicidal ideation 1
- Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
Managing Withdrawal Symptoms
Integrate cognitive behavioral therapy (CBT) during the taper, as this significantly increases success rates. 1 Additional supportive measures include mindfulness and relaxation techniques, sleep hygiene education, and exercise training. 1
Consider adjunctive medications for specific withdrawal symptoms:
- Gabapentin for anxiety and irritability: Start 100-300 mg at bedtime or three times daily, increase by 100-300 mg every 1-7 days as tolerated 1
- Clonidine or tizanidine for autonomic symptoms (sweating, tachycardia) 2
- Trazodone for insomnia 2
- Carbamazepine may help mitigate withdrawal symptoms, particularly for patients on ≥20 mg/day diazepam equivalents 1, 3
Critical Safety Considerations
Abrupt discontinuation of diazepam can cause seizures and death and is never appropriate. 1, 4 The FDA explicitly warns that gradual tapering is required to reduce the risk of withdrawal reactions. 4
If a patient develops withdrawal reactions, pause the taper or increase the dosage to the previous tapered dosage level, then decrease more slowly. 4 This is standard FDA guidance and should be followed rigorously.
Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1 Once physiological dependence has decreased through tapering, returning to the original dose can cause respiratory depression and death. 1
Special Populations
Pregnant patients should not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor. 1 This is an absolute contraindication to unsupervised tapering. 1
Elderly patients require more gradual tapers with smaller dose reductions to minimize adverse effects. 1 Benzodiazepines in elderly patients are associated with cognitive impairment, falls, fractures, and loss of functional independence. 1
When to Refer to a Specialist
Refer immediately if the patient has:
- History of withdrawal seizures 1
- Unstable psychiatric comorbidities 1
- Co-occurring substance use disorders 1
- Previous unsuccessful office-based tapering attempts 1
Realistic Timeline and Expectations
The taper will likely take 6-12 months minimum, and possibly longer. 1 For patients on diazepam for years, the taper may take 1-2 years or more. 1 Some patients may benefit from maintenance at a reduced dose rather than complete discontinuation—the target dose does not need to be zero. 2
Tapers may be considered successful as long as the patient is making progress. 5 Once the smallest available dose is reached (typically 2 mg), the interval between doses can be extended before complete discontinuation. 5
Key Pitfalls to Avoid
Never taper too quickly. 1 Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1
Never abandon the patient who is struggling with the taper. 1 Consider pausing rather than discontinuing care. 1 Patient agreement and interest in tapering is a key component of success. 1
Never set arbitrary time limits for completing the taper. 1 The goal is durability of the taper, not speed. 2
Concurrent Opioid Use
If a patient is taking both opioids and benzodiazepines and both need to be discontinued, reduce the benzodiazepines first due to the higher risks associated with their withdrawal. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal, including seizures and death. 1