Safe Discontinuation of Xanax 0.25 mg BID
For a patient on alprazolam 0.25 mg twice daily (total 0.5 mg/day), reduce the dose by 10-25% of the current dose every 1-2 weeks, which translates to decreasing by 0.125 mg (one-quarter tablet) every 1-2 weeks until complete discontinuation is achieved over approximately 6-8 weeks. 1
Critical Safety Framework
Abrupt discontinuation of alprazolam is never appropriate and can cause seizures and death—this risk exists even at low doses like 0.5 mg/day. 1, 2 The FDA explicitly warns that withdrawal symptoms, including seizures, have been reported after only brief therapy with alprazolam at doses within the recommended range (0.75 to 4 mg/day), and signs and symptoms of withdrawal are more prominent after rapid decrease or abrupt discontinuance. 2
Recommended Tapering Protocol
Week-by-Week Schedule
Always reduce by a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions. 1
Weeks 1-2: Reduce from 0.5 mg/day to 0.375 mg/day (25% reduction)
- Take 0.25 mg in morning, 0.125 mg in evening 1
Weeks 3-4: Reduce to 0.25 mg/day (approximately 33% of current dose)
- Take 0.125 mg twice daily, or 0.25 mg once daily 1
Weeks 5-6: Reduce to 0.125 mg/day (50% of current dose)
- Take 0.125 mg once daily 1
Weeks 7-8: Extend dosing interval before complete discontinuation
- Take 0.125 mg every other day for 1-2 weeks, then discontinue 1
The taper rate must be determined by the patient's tolerance, not a rigid schedule, and pauses are acceptable and often necessary when withdrawal symptoms emerge. 1
Monitoring Requirements
Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases. 1 At each visit, assess for:
- Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion 1, 2
- Severe symptoms requiring immediate attention: seizures, altered mental status, severe psychological distress, panic attacks, suicidal ideation 1
- Functional status: ability to maintain daily activities 1
Adjunctive Strategies to Improve Success
Non-Pharmacological Support (Highest Priority)
Integrate cognitive-behavioral therapy (CBT) during the taper, as this significantly increases success rates. 1 Additional supportive measures include:
- Mindfulness and relaxation techniques 1
- Sleep hygiene education 1
- Exercise and fitness training 1
- Patient education about benzodiazepine risks and benefits of tapering 1, 3
Pharmacological Adjuncts (If Needed)
Gabapentin can help mitigate withdrawal symptoms: Start with 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated (adjust dose in renal insufficiency). 1
Other options with limited evidence include:
- Carbamazepine (may affect alprazolam metabolism) 1
- Pregabalin 1
- SSRIs (particularly paroxetine) for underlying anxiety 1
- Trazodone 25-200 mg for short-term insomnia management 1
When to Pause the Taper
Clinically significant withdrawal symptoms signal the need to slow the taper rate or pause entirely. 1 Specific pause criteria include:
- Moderate to severe withdrawal symptoms (anxiety, tremor, insomnia, etc.) 1
- Severe psychological distress, depression, panic attacks, or suicidal ideation 1
- Functional decline where patient cannot maintain daily activities 1
When pausing, maintain the current dose for 2-4 weeks until symptoms resolve, then restart at the same dose where the pause occurred—never increase the dose. 1
When to Refer to a Specialist
Immediate specialist referral is indicated for: 1
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders
- Previous unsuccessful office-based tapering attempts
Critical Pitfalls to Avoid
Never taper too quickly: Even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1
Never use straight-line percentage reductions from the starting dose: This subjects patients to disproportionately large final decrements. 1
Never abandon the patient: Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy as a legitimate outcome. 1
Never substitute another benzodiazepine at this low dose: The patient is already on a minimal dose, and substitution adds unnecessary complexity. 1
Realistic Timeline and Expectations
The taper will likely take 6-8 weeks minimum for this dose, possibly longer if withdrawal symptoms emerge. 1 Patient agreement and interest in tapering is a key component of success. 1 The goal is durability of the taper, not speed—tapers may be considered successful as long as the patient is making progress. 1
After successful discontinuation, patients typically experience improved psychomotor and cognitive functioning, particularly in memory and daytime alertness. 1