What is the recommended dispensing protocol for a patient converting from alprazolam (Xanax) 0.5mg to lorazepam (Ativan) 1mg for anxiety management, including tablet quantity, days' supply, and refills?

Dispensing Protocol for Alprazolam to Lorazepam Conversion

Critical Context Recognition

The provided evidence addresses pediatric benzodiazepine weaning protocols and does not apply to adult outpatient anxiety management with alprazolam-to-lorazepam conversion. The question requires standard adult benzodiazepine prescribing practices, which are not adequately covered in the supplied evidence.

Standard Adult Dispensing Recommendation

For an adult patient converting from alprazolam 0.5mg to lorazepam 1mg for anxiety, dispense #60 tablets, for a 30-day supply, with 0-2 refills maximum, following controlled substance regulations. 1

Dosing Framework

• Lorazepam 1mg is approximately equivalent to alprazolam 0.5mg based on standard benzodiazepine equivalency tables 2
• The FDA-approved dosing for anxiety is 2-6 mg/day in divided doses, with most patients requiring 2-3 mg/day given twice or three times daily 1
• For a patient on lorazepam 1mg, the typical regimen would be 1mg twice daily (2mg total daily dose) 1

Tablet Quantity Calculation

• 1mg twice daily = 2 tablets per day
• 30-day supply = 60 tablets 1
• This represents a conservative, standard monthly supply for controlled substance prescribing

Days Supply

• Specify 30 days on the prescription 1
• This aligns with standard controlled substance monitoring practices and allows for monthly clinical reassessment

Refills

• Limit to 0-2 refills maximum for benzodiazepines in anxiety management
• The FDA label emphasizes individualized duration of therapy and gradual discontinuation planning 1
• Long-term benzodiazepine use (>3 months) is associated with dependence risk, requiring careful monitoring 3

Critical Prescribing Considerations

Withdrawal Risk Management

• Never abruptly discontinue benzodiazepines - both alprazolam and lorazepam require gradual tapering 1, 4
• If converting from alprazolam, ensure the patient has been successfully transitioned before discontinuing alprazolam entirely 4
• Alprazolam withdrawal can cause recurrent panic attacks, malaise, weakness, insomnia, and tachycardia even with gradual tapering 4

Dose Adjustment Protocol

• Start with the lowest effective dose and increase gradually as needed 1
• For elderly or debilitated patients, initial dosage should be 1-2 mg/day in divided doses 1
• When higher dosage is indicated, increase the evening dose before daytime doses 1

Duration of Therapy Expectations

• Most patients maintained or decreased their initial benzodiazepine dose over time when used appropriately 3
• The average therapeutic doses in long-term users were lorazepam 2.7 mg/day and alprazolam 1.2 mg/day 3
• Plan for regular reassessment rather than indefinite refills

Common Prescribing Pitfalls

• Avoid PRN-only prescribing initially - lorazepam for anxiety requires scheduled dosing for optimal therapeutic effect 1
• Do not provide excessive quantities - larger supplies increase diversion risk and delay clinical reassessment
• Monitor for dose escalation - while therapeutic use typically involves stable or decreasing doses, some patients may develop tolerance 3
• Document the clinical indication clearly - this supports appropriate controlled substance prescribing practices

Practical Prescription Format

Lorazepam 1mg tablets

• Dispense: #60 tablets
• Sig: Take 1 tablet by mouth twice daily
• Days supply: 30 days
• Refills: 0-2 (depending on clinical stability and follow-up plan)