Benzodiazepine Cross-Taper: Ativan to Klonopin
For a patient on lorazepam (Ativan) 3 mg daily for 4 weeks, convert to an equivalent dose of clonazepam (Klonopin) 1.5 mg daily, then taper by reducing 25% of the current dose every 1-2 weeks until discontinuation. 1
Conversion and Initial Dosing
Convert lorazepam 3 mg daily to clonazepam 1.5 mg daily (using a 2:1 conversion ratio), divided into twice-daily dosing (0.75 mg twice daily). 1, 2 This conversion should be done directly without overlap, as both are benzodiazepines with similar mechanisms of action.
Recommended Tapering Schedule
Week 1-2: Clonazepam 1.5 mg daily (0.75 mg twice daily) - stabilization phase 1
Week 3-4: Reduce to 1.125 mg daily (0.5 mg AM, 0.625 mg PM) - 25% reduction 1
Week 5-6: Reduce to 0.875 mg daily (0.375 mg AM, 0.5 mg PM) - 22% reduction of current dose 1
Week 7-8: Reduce to 0.625 mg daily (0.25 mg AM, 0.375 mg PM) - 29% reduction of current dose 1
Week 9-10: Reduce to 0.5 mg daily (0.25 mg twice daily) 2
Week 11-12: Reduce to 0.25 mg daily (0.25 mg at bedtime) 2
Week 13-14: Reduce to 0.125 mg daily (0.125 mg at bedtime) 2
Week 15: Discontinue 2
Critical Safety Considerations
Abrupt discontinuation of benzodiazepines can cause seizures and death - gradual tapering is mandatory. 1 This is as dangerous as suddenly stopping antihypertensives or antihyperglycemics. 1
Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1 If the patient were on both opioids and benzodiazepines, the benzodiazepine taper would take precedence. 1
The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 1 If withdrawal symptoms emerge, pause the taper or return to the previous well-tolerated dose. 1
Managing Withdrawal Symptoms
Monitor for withdrawal symptoms including: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion. 1 In severe cases, seizures can occur. 1
Adjunctive medications to mitigate withdrawal symptoms: 1
- Gabapentin: 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
- Carbamazepine: Can help mitigate withdrawal symptoms, though may affect alprazolam metabolism 1
- Pregabalin: Has shown potential benefit in facilitating benzodiazepine tapering 1
- For insomnia: Trazodone for short-term use 3
- For anxiety: Consider SSRIs (like paroxetine) to manage underlying anxiety during tapering 1
Non-Pharmacological Support
Integrate cognitive behavioral therapy (CBT) during the taper - this significantly increases success rates. 1 Additional supportive measures include mindfulness and relaxation techniques, sleep hygiene education, and exercise training. 1
Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement in the tapering process. 1
Monitoring Requirements
- Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
- Monitor for withdrawal symptoms, mood changes, and suicidal ideation. 1
- Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
- Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1
When to Refer to a Specialist
Immediate specialist referral is indicated for: 1
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders
- Previous unsuccessful office-based tapering attempts
Key Pitfalls to Avoid
Never taper too quickly - reductions of 25% every 1-2 weeks are the recommended maximum rate. 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 during tapering - continued support and monitoring are essential. 1
Do not reduce by a percentage of the original dose - always reduce by a percentage of the current dose to prevent disproportionately large final reductions. 1
Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1
Special Considerations for This Patient
Since this patient has only been on lorazepam for 4 weeks (short-term use), the taper can proceed at the standard rate of 25% reductions every 1-2 weeks. 1 Patients on benzodiazepines for more than 1 year would require slower tapers of 10% per month. 1
The total taper duration of approximately 15 weeks is appropriate for this duration of use. 1 The goal is durability of the taper, not speed. 1