How to taper off Ativan (lorazepam) 1mg twice a day (BID)?

How to Taper Off Ativan (Lorazepam) 1mg BID

Reduce lorazepam by 10-25% of the current dose every 1-2 weeks, with the taper likely requiring a minimum of 6-12 months, and never discontinue abruptly as this can cause seizures and death. 1, 2

Critical Safety Considerations

• Abrupt discontinuation of benzodiazepines can cause life-threatening withdrawal including seizures and death and is never appropriate 1, 2
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually 1
• If the patient is also taking opioids, taper the benzodiazepine first due to higher withdrawal risks 1

Recommended Tapering Protocol

Initial Assessment Before Starting

• Assess for concurrent substance use disorders, psychiatric comorbidities, and history of withdrawal seizures 1
• Patients with history of withdrawal seizures, unstable psychiatric comorbidities, or co-occurring substance use disorders should be referred to a specialist immediately 1

Tapering Schedule for Lorazepam 1mg BID (2mg total daily)

Standard taper (for most patients):

• Reduce by 10-25% of the current dose every 1-2 weeks 1
• The reduction is based on the current dose, not the original dose - this prevents disproportionately large final reductions 1

Example schedule starting from 2mg/day:

• Weeks 1-2: Reduce to 1.5mg/day (25% reduction)
• Weeks 3-4: Reduce to 1.2mg/day (20% of current dose)
• Continue reducing by 10-25% of current dose every 1-2 weeks 1

For patients on benzodiazepines >1 year:

• Consider extending to 10% reduction per month rather than every 1-2 weeks 1
• This slower approach is better tolerated for long-term users 1

Adjusting Dosing Intervals

• Once the smallest available dose is reached, extend the interval between doses (from BID to daily, then every other day) before complete discontinuation 3
• The dosage interval can be increased gradually to every 8h, then every 12h, then every 24h, then every other day before discontinuation 3

Managing the Taper Process

Key Principles

• The taper rate must be determined by the patient's tolerance, not a rigid schedule 1
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
• The taper is considered successful as long as progress is being made, even with temporary pauses 1
• Expect the taper to take 6-12 months minimum, possibly longer 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for withdrawal symptoms including: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 1

Adjunctive Support Strategies

Pharmacological Adjuncts

• Carbamazepine can help mitigate withdrawal symptoms, though it may affect drug metabolism 1
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering 1
• Gabapentin can help mitigate withdrawal symptoms; start with 100-300mg at bedtime or three times daily, increasing by 100-300mg every 1-7 days as tolerated 1
• Trazodone for short-term management of insomnia during tapering 1
• NSAIDs or acetaminophen for muscle aches 1

Non-Pharmacological Support

• Cognitive behavioral therapy (CBT) during the taper significantly increases success rates 1
• Additional supportive measures include mindfulness, relaxation techniques, sleep hygiene education, and exercise 1
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 1

Common Pitfalls to Avoid

• Never taper too quickly - research shows even 10% reduction every 3 days resulted in only 24% successful completion 1
• Never abandon the patient even if tapering is unsuccessful; maintain the therapeutic relationship and consider maintenance therapy 1
• Do not use a rigid schedule - adjust based on patient tolerance 1
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 1

Special Populations

Elderly Patients

• Use lower doses and more gradual tapers due to risks of cognitive impairment, falls, fractures, and loss of functional independence 1
• Long-acting agents pose particular concerns for sedation and fall risk 1

Pregnant Patients

• Do not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 1

When to Refer to Specialist

Immediate specialist referral is indicated for:

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Previous unsuccessful office-based tapering attempts 1