What is the diazepam equivalent dose for a patient taking alprazolam 1 mg twice daily?

Alprazolam to Diazepam Conversion

For a patient taking alprazolam 1 mg twice daily (total 2 mg/day), the equivalent diazepam dose is 20 mg per day, typically administered as 10 mg twice daily.

Conversion Ratio and Calculation

The standard benzodiazepine equivalency conversion uses a 1:10 ratio of alprazolam to diazepam 1, 2, 3. This means:

• Alprazolam 1 mg = Diazepam 10 mg 2
• Total daily alprazolam dose: 1 mg × 2 = 2 mg/day
• Equivalent diazepam dose: 2 mg × 10 = 20 mg/day 1

The typical dosing schedule would be diazepam 10 mg twice daily, though diazepam's longer half-life (20-120 hours) may eventually allow for less frequent dosing once the patient stabilizes 4.

Why This Conversion Matters

Diazepam is strongly preferred over alprazolam for long-term management and tapering because its longer half-life provides more protection against withdrawal seizures and produces smoother, less severe withdrawal symptoms 5. Alprazolam carries higher reinforcing properties and greater abuse liability compared to diazepam, particularly in benzodiazepine-dependent patients 3.

Critical Safety Considerations

• Never use a 1:1 conversion ratio—this will result in dangerous underdosing and precipitate withdrawal symptoms including seizures 1
• Abrupt discontinuation of alprazolam can cause seizures and death; any conversion or taper must be gradual 5
• Elderly or debilitated patients require dose reduction (start with 50% of the calculated equivalent dose) due to increased sensitivity 1
• Monitor for respiratory depression, especially if the patient takes concurrent opioids or other CNS depressants 1

Practical Conversion Algorithm

When switching from alprazolam to diazepam:

1. Calculate total daily alprazolam dose (in this case: 2 mg/day)
2. Apply the 1:10 conversion ratio (2 mg × 10 = 20 mg diazepam/day) 1, 2
3. Divide into twice-daily dosing initially (10 mg BID) to match the original dosing frequency 1
4. After 48-72 hours of stability, consider transitioning to once-daily or less frequent dosing due to diazepam's long half-life 4, 1
5. Watch for paradoxical agitation (occurs in ~10% of patients) and withdrawal symptoms 1

Common Pitfalls to Avoid

• Do not assume equal milligram-to-milligram potency—alprazolam is approximately 10 times more potent than diazepam 2, 3
• Do not switch abruptly—consider a gradual cross-taper if the patient has been on alprazolam long-term 5
• Do not ignore concurrent medications—patients on opioids have 67% higher odds of receiving high-dose benzodiazepines and face increased overdose risk 6

Long-Term Considerations

If the goal is eventual benzodiazepine discontinuation rather than simple conversion, diazepam is the preferred agent for tapering due to its pharmacokinetic properties 5. The conversion to diazepam 20 mg/day would be the first step, followed by a gradual taper of 10-25% of the current dose every 1-2 weeks for short-term users, or 10% per month for patients on benzodiazepines longer than one year 5.