Tapering Diazepam from 2mg Daily
From 2mg daily diazepam, reduce to 1.5mg daily (a 25% reduction) for the next 1-2 weeks, then continue reducing by 10-25% of the current dose every 1-2 weeks until discontinuation. 1, 2
Recommended Tapering Schedule from 2mg Daily
Calculate each reduction as a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions that can trigger severe withdrawal. 1, 3
Standard Taper Protocol
- Weeks 1-2: Reduce from 2mg to 1.5mg daily (25% reduction) 1, 2
- Weeks 3-4: Reduce from 1.5mg to 1.0-1.125mg daily (20-25% reduction of current dose) 1, 2
- Weeks 5-6: Reduce from 1.0mg to 0.75mg daily (25% reduction) 1, 2
- Weeks 7-8: Reduce from 0.75mg to 0.5mg daily 1, 2
- Weeks 9-10: Reduce from 0.5mg to 0.25mg daily 1, 2
- Final phase: Once at the smallest available dose (0.25mg or less), extend the interval between doses (e.g., every other day) before complete discontinuation 2, 3
Alternative Slower Taper for Long-Term Users
If the patient has been taking diazepam for more than 1 year, consider a 10% reduction of the current dose every 2-4 weeks rather than the standard 25% every 1-2 weeks. 1, 2 This would mean:
- Reduce from 2mg to 1.8mg for 2-4 weeks (10% reduction) 1, 2
- Then reduce from 1.8mg to 1.62mg for 2-4 weeks (10% of current dose) 1, 2
- Continue this pattern, with each reduction being 10% of the previous dose 1, 2
Critical Monitoring Requirements
Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1, 3 Monitor specifically for:
- Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, or seizures 1, 2, 4
- Mood changes and suicidal ideation 1, 3
- Emergence of depression, anxiety, or substance use disorders that may be revealed by the taper 5, 1
Managing Withdrawal Symptoms
If withdrawal symptoms become severe, slow the taper or temporarily return to the previous dose. 2 The taper rate must be determined by the patient's tolerance, not rigid adherence to schedule. 1, 3
Pharmacological Support Options
- Gabapentin: Start at 100-300mg at bedtime or three times daily, increasing by 100-300mg every 1-7 days as tolerated to help mitigate withdrawal symptoms 1, 3
- For insomnia: Trazodone for short-term management 1
- For muscle aches: NSAIDs or acetaminophen 1
Non-Pharmacological Support
Integrate cognitive-behavioral therapy (CBT) during the taper, as this significantly increases success rates. 1, 2, 3 Additional supportive measures include mindfulness, relaxation techniques, sleep hygiene education, and exercise. 1
Special Considerations and Red Flags
Immediate Specialist Referral Required For:
- History of withdrawal seizures 1, 3
- Unstable psychiatric comorbidities 1, 3
- Co-occurring substance use disorders 1, 3
- Previous unsuccessful office-based tapering attempts 1, 3
Special Populations
- Elderly patients: Require more gradual tapers with smaller dose reductions due to increased risks of sedation, cognitive impairment, and falls 1, 2
- Pregnant patients: Should not taper without specialist consultation due to risk of spontaneous abortion and premature labor 1, 3
- Patients with debilitating disease: May require even more gradual tapering 2
Critical Safety Warnings
Never discontinue diazepam abruptly—this can cause seizures and death. 1, 3, 6 Abrupt discontinuation is no more appropriate than suddenly stopping antihypertensives or antihyperglycemics. 5, 1
Warn patients about increased overdose risk if they return to previous doses after tolerance is lost. 5, 1, 3
If the patient is also taking opioids, taper the benzodiazepine first due to higher withdrawal risks. 1 The combination of opioids and benzodiazepines significantly increases risk of respiratory depression and death. 2, 6
Realistic Timeline and Expectations
The taper will likely take a minimum of 6-12 months, possibly longer. 1 Tapers may need to be paused and restarted when the patient is ready, especially when reaching lower doses. 5, 1, 2 Patient agreement and interest in tapering is a key component of success. 5, 1
The goal is durability of the taper, not speed. 1 Some patients may achieve complete discontinuation while others may attain a reduced dosage at which functional benefits outweigh risks. 5