Should I taper off Ativan (lorazepam) or discontinue it abruptly in a patient with a history of seizures and intermittent use?

Benzodiazepine Tapering Required in This Patient

You must taper the Ativan (lorazepam) gradually rather than abruptly discontinue it, even with intermittent use, because abrupt discontinuation can cause life-threatening withdrawal seizures—a particularly dangerous risk in a patient already with a seizure disorder. 1

Critical Safety Rationale

Abrupt benzodiazepine discontinuation is never appropriate and can precipitate acute withdrawal reactions including seizures and death. 2, 1 This risk exists even in patients who report intermittent use, as your patient has been using lorazepam "once or twice a week more consistently within the last couple of months" with a 60-day supply recently dispensed. 3

Seizure Risk is Particularly High in This Patient

• Withdrawal seizures have been documented even with less than 15 days of benzodiazepine use at therapeutic dosages, and your patient has months of intermittent exposure. 3
• Lorazepam withdrawal seizures are well-documented and can be grand mal seizures ranging from single episodes to coma and death. 3, 4
• Your patient's pre-existing seizure disorder on multiple antiepileptic drugs (topiramate, gabapentin, lamotrigine) creates additional vulnerability—abrupt lorazepam cessation could destabilize seizure control. 5

Recommended Tapering Protocol

Initial Taper Schedule

Reduce lorazepam by 25% of the current dose every 1-2 weeks as the standard starting approach. 2 Given her intermittent use pattern (1 mg once or twice weekly), consider:

• Week 1-2: Reduce to 0.75 mg per dose (25% reduction)
• Week 3-4: Reduce to 0.5 mg per dose
• Week 5-6: Reduce to 0.25 mg per dose
• Week 7-8: Discontinue completely

The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not a rigid schedule—pauses are acceptable and often necessary when withdrawal symptoms emerge. 2, 1

Critical Taper Principles

• Reduce by a percentage of the CURRENT dose, not the original dose, to prevent disproportionately large final reductions. 2
• If withdrawal symptoms develop, pause the taper or increase back to the previous dose level, then decrease more slowly. 1
• For patients with long-term use (which applies here given "last couple of months" of regular use), consider extending to 10% reductions per month rather than 25% every 1-2 weeks. 2

Monitoring Requirements During Taper

Follow up at least monthly during the taper, with more frequent contact during difficult phases. 2 Specifically monitor for:

• Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and most critically—seizures 2, 1
• Seizure activity: Any increase in baseline seizure frequency or new seizure types 5
• Cognitive and functional status: Memory, fall risk, driving safety (which are already concerns in this patient) 2
• Mood changes and suicidal ideation: Depression may emerge or worsen during benzodiazepine withdrawal 1

Adjunctive Support Strategies

Pharmacological Adjuncts

Your patient is already on gabapentin for seizures, which can help mitigate benzodiazepine withdrawal symptoms. 2 This is advantageous as:

• Gabapentin starting dosage is typically 100-300 mg at bedtime or three times daily, increased by 100-300 mg every 1-7 days as tolerated 2
• Your patient's current gabapentin dose may already provide some withdrawal symptom protection
• Carbamazepine may have adjunctive properties for benzodiazepine discontinuation, though data are limited. 6

Non-Pharmacological Support

Integrate cognitive behavioral therapy (CBT) during the taper, as this significantly increases success rates. 2, 6 Additional supportive measures include:

• Patient education about benzodiazepine risks and the temporary nature of withdrawal symptoms 2
• Sleep hygiene education rather than substituting another sedative 2
• Mindfulness and relaxation techniques 2

Special Considerations for This Patient

Polypharmacy Concerns

Your patient is on multiple CNS-active medications (topiramate, gabapentin, lamotrigine, lorazepam), which increases cognitive impairment, fall risk, and driving impairment. 1 The decision to discontinue lorazepam is appropriate given:

• Worsening memory problems
• Recent fall history
• Impaired driving
• These adverse effects are consistent with benzodiazepine toxicity in the context of polypharmacy 2

Realistic Timeline

The taper will likely take 6-12 months minimum, possibly longer, and this extended timeline is appropriate and necessary for safety. 2 Patient agreement and understanding of this timeline is crucial for success.

When to Refer to Specialist

Refer immediately if: 2

• History of withdrawal seizures develops during the taper
• Unstable psychiatric comorbidities emerge
• Office-based tapering is unsuccessful after appropriate attempts
• Any seizure activity increases beyond baseline

Critical Pitfalls to Avoid

• Never taper too quickly: Research shows even a 10% reduction every 3 days resulted in only 24% successful completion 2
• Never abandon the patient during the taper: Consistent follow-up is essential 2
• Never abruptly discontinue: This is equivalent to suddenly stopping antihypertensives or antihyperglycemics in terms of inappropriateness 2, 1
• Do not assume intermittent use is safe to stop abruptly: Withdrawal seizures occur even with short-term therapeutic use 3

The goal is durability of the taper, not speed—tapers are considered successful as long as the patient is making progress. 2