Benzodiazepine Tapering from 2mg Lorazepam (Ativan)
For a patient taking 2mg daily lorazepam, reduce the dose by 10-25% of the current dose every 1-2 weeks, which translates to an initial reduction of 0.2-0.5mg every 1-2 weeks, with the entire taper requiring a minimum of 6-12 months. 1
Critical Safety Framework
Abrupt discontinuation of benzodiazepines can cause seizures and death—never stop suddenly. 1, 2 This risk is equivalent to suddenly stopping antihypertensives or antihyperglycemics. 1
The FDA label for lorazepam explicitly states: "use a gradual taper to discontinue lorazepam or reduce the dosage" to reduce the risk of withdrawal reactions. 2
Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1 If the patient is also taking opioids, taper the benzodiazepine first due to higher withdrawal risks. 1
Specific Tapering Protocol for 2mg Lorazepam
Initial Reduction Strategy
Reduce by percentage of current dose, not original dose, to prevent disproportionately large final reductions. 1 This is a critical distinction that many clinicians miss.
Month 1: Reduce from 2mg to 1.8mg daily (10% reduction) 1
Month 2: Reduce to 1.6mg daily (10% of 1.8mg) 1
Month 3: Reduce to 1.45mg daily (10% of 1.6mg) 1
Continue this pattern of 10% monthly reductions. 1
Alternative Faster Taper (If Patient Has Used <1 Year)
For patients on benzodiazepines less than 1 year, you may reduce by 10-25% of the current dose every 1-2 weeks. 1 This would mean:
- Week 1-2: 2mg → 1.5-1.8mg (0.2-0.5mg reduction)
- Week 3-4: Reduce by 10-25% of the new current dose
- Continue this pattern 1
For Long-Term Users (>1 Year)
Slow to 10% of the current dose per month to minimize withdrawal symptoms. 1 The 6-12 month minimum timeline applies here. 1
Critical Principle: Patient-Determined Rate
The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 1 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge. 1
If clinically significant withdrawal symptoms appear, further slow the taper rate or pause entirely. 1 If the patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level, then decrease more slowly. 2
Monitoring Requirements
Follow up at least monthly during the taper, with more frequent contact during difficult phases. 1
Monitor specifically for withdrawal symptoms including: 1
- Anxiety, tremor, insomnia
- Sweating, tachycardia, headache
- Weakness, muscle aches, nausea
- Confusion or altered mental status
- Seizures (medical emergency)
Screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 1
Adjunctive Pharmacological Support
Gabapentin (First-Line Adjunct)
Start gabapentin 100-300mg at bedtime or three times daily, increasing by 100-300mg every 1-7 days as tolerated to mitigate withdrawal symptoms. 1 Adjust dosage in patients with renal insufficiency. 1
Other Options
Carbamazepine can help mitigate withdrawal symptoms, though it may affect metabolism of some benzodiazepines. 1
Pregabalin has shown potential benefit in facilitating benzodiazepine tapering. 1
SSRIs (particularly paroxetine) may manage underlying anxiety during tapering, but require 4-6 weeks for full effect. 1, 3
Buspirone is the preferred anxiolytic for managing rebound anxiety after discontinuation, with 1-2 week lag time before anxiolytic effects become apparent. 3
Symptomatic Management
- For insomnia: Trazodone 25-200mg can be used for short-term management. 1
- For muscle aches: NSAIDs or acetaminophen. 1
- For nausea: Antiemetics as needed. 1
Non-Pharmacological Support (Essential for Success)
Integrating cognitive-behavioral therapy (CBT) during the taper significantly increases success rates. 1, 3 This is not optional—it substantially improves outcomes.
Additional supportive measures include: 1
- Mindfulness and relaxation techniques
- Sleep hygiene education
- Exercise and fitness training
- Patient education about benzodiazepine risks and benefits of tapering
When to Refer to Specialist Immediately
Refer patients with: 1
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders
- Previous unsuccessful office-based tapering attempts
Special Considerations for Elderly Patients
Use lower doses and more gradual tapers for elderly patients. 1 Lorazepam is actually safer than long-acting benzodiazepines like diazepam in elderly patients due to reduced sedation and fall risk. 1
Benzodiazepines in elderly patients are associated with cognitive impairment, reduced mobility, falls, fractures, and loss of functional independence. 1
Critical Pitfalls to Avoid
Never use straight-line percentage reductions from the starting dose—this subjects patients to disproportionately large final decrements. 1
Never substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks. 3
Never abandon the patient, even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy. 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
Realistic Timeline and Goals
The taper will likely take 6-12 months minimum, and possibly longer. 1 Patient agreement and interest in tapering is a key component of success. 1
Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1
Once the smallest available dose is reached (lorazepam 0.5mg), the interval between doses can be extended before complete discontinuation. 1
Pregnancy Consideration
Pregnant patients should not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor. 1