What is the protocol for benzodiazepine (BZD) taper?

From the Guidelines

A benzodiazepine taper should be gradual, typically reducing the dose by 10-25% every 1-2 weeks, as recommended by the most recent and highest quality study 1.

Key Considerations

• The taper schedule should be individualized based on the patient's duration of use, dose, and symptoms.
• Patients should be monitored for withdrawal symptoms including anxiety, insomnia, irritability, tremor, and rarely seizures.
• Adjunctive treatments like cognitive behavioral therapy, relaxation techniques, and temporary use of non-benzodiazepine medications (such as hydroxyzine 25-50mg as needed for anxiety or trazodone 50-100mg for sleep) can help manage symptoms during the taper.
• Longer-acting benzodiazepines like diazepam (5-10mg equivalent to 1mg lorazepam) are often preferred for tapering due to their smoother withdrawal profile.

Tapering Process

• The taper process may take weeks to months depending on the duration of prior use, with longer tapers generally needed for those who have been on benzodiazepines for years.
• Gradual tapering is essential because abrupt discontinuation can lead to severe withdrawal symptoms including seizures, especially with high doses or long-term use.
• Education about benzodiazepine risks and benefits of tapering, as well as patient empowerment, can increase the success of tapering, as shown in the EMPOWER trial 1.

Additional Recommendations

• Consider safer alternatives to benzodiazepines, such as psychological or pharmacological treatments, including antidepressants, cognitive-behavioral therapy, and integrative strategies 1.
• When considering deprescribing of antipsychotics, a gradual withdrawal strategy is recommended to minimize potential discontinuation effects 1.

From the FDA Drug Label

The risk of seizure seems to be greatest 24-72 hours after discontinuation (see DOSAGE AND ADMINISTRATION for recommended tapering and discontinuation schedule). Withdrawal reactions may occur when dosage reduction occurs for any reason. It is recommended that all patients on alprazolam tablets who require a dosage reduction be gradually tapered under close supervision (see WARNINGS and DOSAGE AND ADMINISTRATION). Patients, especially individuals with a history of seizures or epilepsy, should not be abruptly discontinued from any CNS depressant agent, including alprazolam tablets

• Benzodiazepine taper should be done gradually to minimize the risk of seizures and withdrawal symptoms.
• The risk of seizure is greatest 24-72 hours after discontinuation.
• Close supervision is recommended when tapering patients off alprazolam tablets 2.
• Gradual tapering is also recommended to minimize the risk of psychological dependence and addiction 2.
• Patients with a history of seizures or epilepsy should not be abruptly discontinued from alprazolam tablets 2 2.

From the Research

Benzodiazepine Taper Overview

• Benzodiazepine tapering is a process used to help individuals safely stop using benzodiazepines after long-term use or abuse 3, 4, 5, 6.
• The goal of tapering is to gradually reduce the dose of the benzodiazepine to minimize withdrawal symptoms and prevent complications 3, 5.

Tapering Methods

• One study found that a gradual reduction of diazepam dose by 10% per day was an effective and safe approach for detoxifying abusers of high doses of benzodiazepines 3.
• Another study found that patient education and cognitive behavioral therapy (CBT) were effective in increasing benzodiazepine discontinuation success, while the use of medications to help improve tapering success was inconclusive 4.
• A randomized clinical trial found that a program combining masked tapering with novel cognitive and behavioral exercises targeting placebo mechanisms improved the percentage of long-term benzodiazepine receptor agonist discontinuation compared with standard CBTI plus an unmasked taper 6.

Withdrawal Symptoms and Management

• Withdrawal symptoms from benzodiazepines can be severe and life-threatening, and require careful management 5.
• One study found that anticonvulsants such as valproic acid, carbamazepine, and gabapentin may be useful in the treatment of neuropathic pain and withdrawal from benzodiazepines 7.
• Clonazepam is also commonly used for benzodiazepine withdrawal, but more research is needed to explore alternative methods of treating benzodiazepine withdrawal 5.

Special Considerations

• Benzodiazepine tapering in the elderly population requires special consideration, as long-term use can lead to impaired cognitive functioning, medication dependence, and increased risks for adverse drug reactions 4.
• Patient education and CBT may be particularly effective in this population, but more research is needed to determine the best approaches for benzodiazepine tapering in older adults 4.