What is an appropriate taper schedule to discontinue diazepam 5 mg daily before starting eszopiclone (Lunesta) 3 mg for insomnia?

Diazepam to Eszopiclone Transition: Taper Schedule

You should taper diazepam 5 mg daily over approximately 4-5 months using a gradual dose reduction protocol before starting eszopiclone, reducing by 10% of the current dose every 2-4 weeks to minimize withdrawal risks including seizures. 1, 2

Critical Safety Framework

Abrupt discontinuation of diazepam is never appropriate and can cause seizures and death—this is equivalent to suddenly stopping antihypertensives or antihyperglycemics. 1, 3 The FDA label explicitly requires gradual tapering to reduce withdrawal reaction risks. 3

Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1 Withdrawal symptoms include anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and potentially seizures. 1, 4

Recommended Tapering Protocol

Weeks 1-2: Reduce to 4.5 mg daily

• Decrease by 0.5 mg (10% of 5 mg) 1, 2
• Monitor for withdrawal symptoms at each reduction 2

Weeks 3-4: Reduce to 4 mg daily

• Decrease by 0.5 mg (approximately 11% of current dose) 1
• This follows the principle of reducing by percentage of current dose, not original dose 1

Weeks 5-6: Reduce to 3.5 mg daily

• Decrease by 0.5 mg 1

Weeks 7-8: Reduce to 3 mg daily

• Decrease by 0.5 mg 1

Weeks 9-10: Reduce to 2.5 mg daily

• Decrease by 0.5 mg 1

Weeks 11-12: Reduce to 2 mg daily

• Decrease by 0.5 mg 1
• This is the smallest available tablet strength for diazepam 2

Weeks 13-16: Reduce to 1.5 mg daily

• Decrease by 0.5 mg over 4 weeks (slower taper as dose gets lower) 1, 2

Weeks 17-20: Reduce to 1 mg daily

• Decrease by 0.5 mg over 4 weeks 1

Weeks 21-24: Reduce to 0.5 mg daily

• Decrease by 0.5 mg over 4 weeks 1

Weeks 25-28: Extend dosing interval

• Once below 2 mg daily, extend the interval between doses (e.g., every other day) before complete discontinuation 2
• Diazepam can be stopped when taken less frequently than once daily 2

Week 29+: Complete discontinuation

• After successful interval extension, discontinue completely 2

When to Pause or Slow the Taper

If clinically significant withdrawal symptoms emerge, pause the taper for 2-4 weeks at the current dose. 1, 2 Significant symptoms include:

• Severe anxiety or panic attacks 1
• Tremor, excessive sweating, tachycardia 1
• Insomnia or nightmares 5
• Functional decline affecting daily activities 1

The taper rate must be determined by your tolerance, not a rigid schedule—pauses are acceptable and often necessary. 1, 2 Consider the taper successful as long as you are making progress, even with temporary pauses. 2

For patients on benzodiazepines longer than 1 year, slowing to 10% per month (rather than every 2 weeks) may be better tolerated. 1, 2

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor specifically for withdrawal symptoms at each dose reduction 2
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1

Adjunctive Strategies to Improve Success

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated. 6, 1 CBT is particularly helpful for patients struggling with discontinuation. 1

Additional supportive measures include:

• Sleep hygiene education 1
• Mindfulness and relaxation techniques 1
• Patient education about benzodiazepine risks and benefits of tapering 1

Consider pharmacological adjuncts for specific withdrawal symptoms:

• Gabapentin 100-300 mg at bedtime or three times daily, titrated by 100-300 mg every 1-7 days as tolerated (adjust in renal insufficiency) 1
• Trazodone 25-200 mg for short-term insomnia management during taper 1
• Carbamazepine may help mitigate withdrawal symptoms 1, 7

Starting Eszopiclone After Diazepam Discontinuation

Wait at least 1-2 weeks after complete diazepam discontinuation before starting eszopiclone 3 mg to ensure withdrawal symptoms have resolved and to avoid substituting one sleep medication dependence for another. 6, 8

Eszopiclone has demonstrated efficacy for chronic insomnia without significant rebound insomnia or serious withdrawal effects on discontinuation. 8, 9 However, some patients experienced mild withdrawal symptoms (anxiety, abnormal dreams, nausea) after stopping eszopiclone 2-3 mg. 4

Unlike benzodiazepines, eszopiclone showed no evidence of tolerance during 12 months of treatment and is not limited to short-term use. 8, 9

Critical Pitfalls to Avoid

• Never reduce by a fixed percentage of the original dose—always calculate reductions as a percentage of the current dose to prevent disproportionately large final decrements 1
• Never abandon the taper if unsuccessful—maintenance at a lower dose is a legitimate outcome 1
• Never return to previous higher doses after tolerance is lost—this increases overdose risk 2
• Do not substitute another benzodiazepine or Z-drug immediately—this perpetuates dependence 6

When to Refer to a Specialist

Immediate specialist referral is indicated for:

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Previous unsuccessful office-based tapering attempts 1

Expected Timeline

This protocol requires approximately 5-7 months minimum for safe completion, though some patients may need longer. 1, 2 The goal is durability of the taper, not speed. 1