From the Research
To transition from lorazepam 1mg four times daily (QID) to diazepam twice daily (BID), use an equivalent dose of 10mg diazepam BID, as this approach helps prevent withdrawal symptoms and is supported by the pharmacokinetic properties of diazepam 1. When considering the transition, it's crucial to prioritize the patient's morbidity, mortality, and quality of life. The most recent and highest quality study, although not directly addressing the transition from lorazepam to diazepam, provides insight into the pharmacological management of acute agitation, where lorazepam is noted for its effectiveness with fewer side effects compared to antipsychotics 2. The key to a successful transition is a gradual approach. Start by giving 10mg diazepam in the morning and 10mg in the evening while simultaneously reducing lorazepam by 1mg every 2-3 days. For example, reduce to lorazepam 1mg TID for 2-3 days, then 1mg BID for 2-3 days, then 1mg daily for 2-3 days before stopping completely. Diazepam's longer half-life (20-100 hours) compared to lorazepam (10-20 hours) provides more stable blood levels and smoother withdrawal, with its active metabolites contributing to a more gradual decline in benzodiazepine activity 3. Monitor for withdrawal symptoms like anxiety, insomnia, irritability, or tremors during the transition, and adjust the taper schedule if needed. Some patients may require a more gradual taper, especially if they've been on lorazepam long-term. Once stabilized on diazepam BID, further tapering can be considered if clinically appropriate. It's also worth noting that while diazepam is preferred for tapering due to its pharmacokinetic properties, the choice between benzodiazepines can depend on the specific clinical scenario, including the management of status epilepticus, where lorazepam has been found to have a longer duration of action after a single intravenous injection 4, 3. However, in the context of transitioning from lorazepam to diazepam for the purpose of managing benzodiazepine use and minimizing withdrawal symptoms, the approach outlined above, supported by the pharmacological properties of diazepam and the principles of gradual tapering, is recommended.