Ativan (Lorazepam) Tapering Schedule for 3mg Daily Use Over 4 Weeks
For a patient on lorazepam 3mg daily for 4 weeks, taper by reducing 25% of the current dose every 1-2 weeks, completing discontinuation over approximately 6-8 weeks, as this duration of use represents relatively short-term exposure with lower risk of severe withdrawal compared to long-term users. 1
Recommended Tapering Protocol
Week-by-Week Schedule
Week 1-2: Reduce to 2.25mg daily (25% reduction from 3mg)
- This represents the initial 25% reduction recommended by CDC guidelines 1
- Monitor for mild withdrawal symptoms including anxiety, tremor, insomnia, or headache 1
Week 3-4: Reduce to approximately 1.5-1.75mg daily (25% reduction from current dose)
- Continue reducing by 25% of the current dose, not the original dose, to prevent disproportionately large final reductions 1
- The taper rate must be determined by patient tolerance, not rigid adherence to schedule 1
Week 5-6: Reduce to approximately 1-1.25mg daily
- As you approach lower doses, consider slowing the taper if withdrawal symptoms emerge 1
- Pauses in the taper are acceptable and often necessary when symptoms occur 1
Week 7-8: Reduce to 0.5mg daily, then discontinue
- Once the smallest available dose is reached, you can extend the interval between doses before complete discontinuation 1
- The FDA label recommends gradual tapering to reduce withdrawal risk 2
Critical Safety Considerations
Never discontinue abruptly - Abrupt cessation can cause seizures and death, making gradual tapering essential 1, 2
Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually 1
If Patient is Also Taking Opioids
Taper the benzodiazepine first before addressing opioid reduction, as benzodiazepine withdrawal poses higher risks 1
Monitoring Requirements
Follow up weekly or biweekly during the taper to assess withdrawal symptoms and adjust the schedule as needed 1
Monitor specifically for:
- Anxiety, tremor, insomnia, sweating, tachycardia 1
- Headache, weakness, muscle aches, nausea 1
- Confusion, altered mental status, or seizures (medical emergency) 1
Managing Withdrawal Symptoms
If withdrawal symptoms become intolerable:
- Slow the taper rate to 10% reductions per month 3
- Consider pausing the taper temporarily 2
- May reinstate the previous dose level, then decrease more slowly 2
Adjunctive medications that may help:
- Gabapentin 100-300mg at bedtime or three times daily, titrated cautiously to mitigate withdrawal symptoms 1
- Carbamazepine may help, though evidence is limited 1
- Short-term trazodone or gabapentin for insomnia and anxiety 3
Non-Pharmacological Support
Cognitive behavioral therapy (CBT) during the taper significantly increases success rates and should be offered if available 1
Additional supportive measures include:
- Patient education about benzodiazepine risks and tapering benefits 1
- Mindfulness and relaxation techniques 1
- Sleep hygiene education 1
Important Caveats
This 6-8 week schedule is appropriate for 4 weeks of use. For patients on benzodiazepines longer than 1 year, extend the taper to 10% per month rather than 25% every 1-2 weeks 1
The taper may take longer than planned - success is measured by progress and durability, not speed 1
When to refer to a specialist immediately:
- History of withdrawal seizures 1
- Unstable psychiatric comorbidities 1
- Co-occurring substance use disorders 1
- Previous unsuccessful tapering attempts 1
Special Populations
Elderly or debilitated patients: Consider more gradual taper with smaller dose reductions (10% of current dose every 2-4 weeks) to minimize adverse effects 1
Pregnant patients: Do not taper without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 1
Key Pitfall to Avoid
Do not reduce by a fixed amount each time - always reduce by a percentage of the current dose, not the original dose, to prevent the final reductions from being disproportionately large and poorly tolerated 1