What is the recommended tapering regimen from lorazepam (Ativan) 1 mg to diazepam (Valium)?

Lorazepam to Diazepam Conversion and Taper Protocol

For a patient taking lorazepam 1 mg daily, convert to diazepam 10 mg daily, then taper the diazepam by 10-25% of the current dose every 1-2 weeks, with the understanding that this process will likely require 6-12 months minimum. 1

Conversion Rationale

Diazepam is the preferred benzodiazepine for tapering due to its long half-life and self-tapering pharmacokinetics. 2 The conversion from lorazepam to diazepam follows a 1:10 ratio, meaning lorazepam 1 mg equals approximately diazepam 10 mg. 3, 4

Why Switch to Diazepam for Tapering?

• Diazepam and its active metabolite desmethyldiazepam have the longest elimination half-lives among benzodiazepines, resulting in gradual self-tapering that produces smoother withdrawal with lower incidence of breakthrough symptoms and rebound phenomena. 2
• The long half-life prevents the sharp peaks and troughs that occur with shorter-acting agents like lorazepam, reducing seizure risk during the taper. 2
• Lorazepam has a shorter duration of action and more abrupt offset, making direct tapering more difficult to tolerate. 3

Step-by-Step Conversion and Taper Protocol

Step 1: Initial Conversion

• Abruptly switch from lorazepam 1 mg to diazepam 10 mg daily. 4, 5
• Monitor closely for the first 24-48 hours to ensure adequate cross-tolerance. 4
• Additional diazepam 5 mg may be given every 4-6 hours as needed for breakthrough withdrawal symptoms during the first 1-2 days. 4

Step 2: Stabilization Period

• Maintain the patient on diazepam 10 mg daily for at least 1-2 weeks before beginning the taper to ensure stabilization. 1
• This allows plasma levels to reach steady state and confirms adequate dosing. 5

Step 3: Tapering Schedule

The taper rate must be determined by the patient's tolerance, not a rigid schedule—pauses are acceptable and often necessary when withdrawal symptoms emerge. 1

Standard Taper (for patients on benzodiazepines <1 year):

• Week 1-2: Reduce to 7.5 mg daily (25% reduction from current dose) 1
• Week 3-4: Reduce to 5-6 mg daily (20-25% reduction from current dose) 1
• Week 5-6: Reduce to 4-5 mg daily (20% reduction from current dose) 1
• Week 7-8: Reduce to 3-4 mg daily (20% reduction from current dose) 1
• Continue reducing by 10-25% of the current dose every 1-2 weeks 1

Extended Taper (for patients on benzodiazepines >1 year):

• Reduce by 10% of the current dose per month rather than every 1-2 weeks. 1
• This slower approach minimizes withdrawal symptoms and improves completion rates. 1

Step 4: Final Discontinuation

• Once the smallest available dose (typically 2 mg) is reached, extend the interval between doses before complete discontinuation. 1
• Example: 2 mg every other day for 1-2 weeks, then 2 mg twice weekly for 1-2 weeks, then discontinue. 1

Critical Safety Considerations

Absolute Contraindications to Rapid Tapering

Abrupt discontinuation of benzodiazepines can cause seizures and death—this is never appropriate and is equivalent to suddenly stopping antihypertensives or antihyperglycemics. 1

High-Risk Patients Requiring Specialist Referral

Immediately refer to a specialist if the patient has: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts
• Pregnancy (benzodiazepine withdrawal can cause spontaneous abortion and premature labor) 1

Concurrent Opioid Use

If the patient is taking both opioids and benzodiazepines, taper the benzodiazepines first due to higher withdrawal risks. 1 This represents updated guidance that supersedes older recommendations to taper opioids first. 1

Monitoring Requirements

Follow-Up Schedule

• Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases. 1
• Monitor for withdrawal symptoms at each visit. 1

Withdrawal Symptoms to Monitor

Assess for: 6, 1

• Anxiety and panic attacks
• Tremor
• Insomnia
• Sweating and tachycardia
• Headache and muscle aches
• Nausea and confusion
• Seizures (medical emergency) 1
• Depression and suicidal ideation 1

Adjunctive Strategies to Improve Success

Psychological Support (Strongly Recommended)

Integrating cognitive behavioral therapy (CBT) during the taper significantly increases success rates. 1 Additional supportive measures include:

• Mindfulness and relaxation techniques 1
• Sleep hygiene education 1
• Exercise and fitness training 1

Pharmacological Adjuncts (Optional)

Consider these medications to manage specific 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: May help mitigate withdrawal symptoms 1
• Pregabalin: Has shown potential benefit 1
• Trazodone: For insomnia during tapering 1
• SSRIs (e.g., paroxetine): For underlying anxiety 1

Important caveat: Antiseizure medications themselves require tapering to avoid substituting one drug dependence for another. 1

Patient Education

Educate the patient about: 1

• Benzodiazepine risks (cognitive impairment, falls, addiction)
• Benefits of tapering
• Expected timeline (6-12 months minimum)
• Withdrawal symptoms and when to seek help
• Increased overdose risk if they return to previous doses after tolerance is lost 1

Common Pitfalls to Avoid

1. Never taper too quickly. Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1

2. Never abandon the patient, even if tapering is unsuccessful. Maintain the therapeutic relationship and consider maintenance therapy. 1

3. 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

4. Do not prescribe additional CNS depressants during the tapering period. 1

5. Do not use rigid schedules. The taper rate must be individualized based on patient tolerance. 1

Special Populations

Elderly Patients

Use lower doses and more gradual tapers in elderly patients due to increased risks of: 1

• Cognitive impairment
• Falls and fractures
• Reduced mobility
• Loss of functional independence

Long-acting agents like diazepam pose particular concerns for sedation and fall risk in this population, but can still be used safely with careful monitoring. 2

Patients with Liver Disease

Contrary to common belief, diazepam can be safely used in patients with liver disease when administered using a symptom-based approach. 2 The fear of prolonged over-sedation is based on conjecture rather than clinical evidence. 2

Realistic Expectations

The taper will likely take 6-12 months minimum, and possibly longer. 1 Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1