What is the recommended taper schedule when converting from lorazepam (Ativan) to diazepam (Valium)?

Lorazepam to Diazepam Conversion and Taper Schedule

Convert lorazepam 1 mg to diazepam 10 mg (1:10 ratio), then taper the diazepam by 10-20% every 3-7 days, extending the taper over weeks to months depending on duration of lorazepam use to minimize withdrawal symptoms and prevent seizures. 1

Conversion Ratio

• Standard equivalency: 1 mg lorazepam = 10 mg diazepam 1, 2
• Diazepam is approximately 5 times less potent than lorazepam on a milligram basis 2
• This conversion accounts for both potency differences and the significantly longer half-life of diazepam (20-100 hours) compared to lorazepam (10-20 hours) 1, 2

Step-by-Step Conversion Protocol

Initial Conversion

• Abruptly switch from lorazepam 1 mg to diazepam 10 mg at the same dosing frequency initially 1, 3
• If patient was taking lorazepam multiple times daily, calculate total daily lorazepam dose and multiply by 10 to get total daily diazepam equivalent 1
• Divide initial diazepam dose into 2-3 administrations per day (every 8-12 hours) 1

Tapering Schedule

For short-term use (<2-4 weeks):

• Reduce diazepam by 20-25% every 3-5 days 1, 3
• Complete taper over 7-14 days 3

For longer-term use (>1 month):

• Reduce diazepam by 10% of the current dose every 1-2 weeks 1
• As dose decreases below 25% of original, slow taper to 5-10% reductions 1
• Total taper duration should extend over several months 1, 4
• Some patients may require reductions as small as 10% of the most recent dose each month 4

Example Taper for Lorazepam 1 mg TID (3 mg/day total)

Week 1: Convert to diazepam 30 mg/day (10 mg TID) 1, 2

Week 2: Reduce to diazepam 24 mg/day (8 mg TID) - 20% reduction 1

Week 3: Reduce to diazepam 20 mg/day (10 mg BID) - 17% reduction 1

Week 4: Reduce to diazepam 16 mg/day (8 mg BID) - 20% reduction 1

Week 5-6: Reduce to diazepam 12 mg/day (6 mg BID) - 25% reduction 1

Week 7-8: Reduce to diazepam 8 mg/day (4 mg BID) - 33% reduction 1

Week 9-10: Reduce to diazepam 5 mg/day (2.5 mg BID) - 37% reduction 1

Week 11-12: Reduce to diazepam 2.5 mg/day (2.5 mg daily) - 50% reduction 1

Week 13-14: Discontinue 1

Critical Monitoring Parameters

• Monitor for withdrawal symptoms: anxiety, tremor, insomnia, seizures, agitation 1, 3
• Withdrawal symptoms from lorazepam typically appear within 24 hours of discontinuation, while diazepam withdrawal may be delayed due to longer half-life 1, 2
• If breakthrough withdrawal occurs, increase dose back to previous level and slow taper rate 1
• Seizure risk is highest during rapid tapers or abrupt discontinuation 1, 5

Special Population Adjustments

Elderly or debilitated patients:

• Use more conservative conversion ratio (consider 1 mg lorazepam = 5 mg diazepam initially) 1
• Extend taper duration by 50-100% 1
• Monitor closely for oversedation and falls 1

Patients with liver disease:

• Lorazepam is preferred over diazepam in hepatic impairment, so conversion may not be ideal 1
• If conversion necessary, use lower diazepam doses and slower taper 1

Common Pitfalls to Avoid

• Do not taper too rapidly - this increases seizure risk and withdrawal severity 1, 5
• Do not use fixed-schedule tapers without clinical assessment - adjust based on individual withdrawal symptoms 1, 3
• Approximately 10% of patients experience paradoxical agitation with benzodiazepines during taper 6
• Final doses before complete cessation may need to be very small (1-2.5 mg diazepam) to prevent large drops in receptor occupancy 4
• Avoid combining with other CNS depressants during taper due to respiratory depression risk 6

Rationale for Diazepam Over Direct Lorazepam Taper

• Diazepam's longer half-life (20-100 hours) provides "self-tapering" effect, smoothing withdrawal symptoms 5
• Long-acting benzodiazepines like diazepam are specifically recommended for preventing seizures during withdrawal 1
• Diazepam allows for more gradual decline in benzodiazepine receptor occupancy 4, 5