What is an appropriate taper schedule for a patient taking lorazepam 0.5 mg at bedtime?

Lorazepam 0.5mg Bedtime Taper Schedule

For a patient taking lorazepam 0.5mg at bedtime, reduce the dose by 10% of the current dose every 2–4 weeks, which translates to approximately 0.05mg reductions initially, continuing until complete discontinuation over a minimum of 3–6 months. 1, 2

Specific Tapering Protocol

Week-by-Week Schedule

Month 1 (Weeks 1–4):

• Reduce from 0.5mg to 0.45mg at bedtime (10% reduction) 1, 2
• Monitor for withdrawal symptoms before proceeding 2

Month 2 (Weeks 5–8):

• Reduce from 0.45mg to 0.40mg at bedtime (approximately 10% of 0.45mg) 1, 2
• Continue monitoring tolerance 2

Month 3 (Weeks 9–12):

• Reduce from 0.40mg to 0.36mg at bedtime 1, 2

Month 4 (Weeks 13–16):

• Reduce from 0.36mg to 0.32mg at bedtime 1, 2

Month 5 (Weeks 17–20):

• Reduce from 0.32mg to 0.29mg at bedtime 1, 2

Month 6 (Weeks 21–24):

• Reduce from 0.29mg to 0.26mg at bedtime 1, 2

Continue this pattern of 10% reductions every 2–4 weeks until reaching the smallest feasible dose (approximately 0.05–0.1mg), then discontinue completely. 1, 2

Critical Adjustment for Long-Term Users

If the patient has been taking lorazepam for ≥1 year, slow the taper to 10% reductions per month (every 4 weeks) rather than every 2 weeks. 1, 2 This extended timeline means complete discontinuation may require 10–12 months or longer. 1, 2

Practical Implementation Challenges

Dosing Precision

Because lorazepam tablets typically come in 0.5mg, 1mg, or 2mg strengths, achieving precise 10% reductions requires either:

• Liquid formulation: Lorazepam oral concentrate allows precise dosing using the calibrated dropper 3
• Tablet splitting: Use a pill cutter for larger tablets, though this becomes impractical below 0.25mg 2
• Compounding pharmacy: Custom capsules or suspensions can provide exact doses 2

The FDA label recommends using the oral concentrate mixed with liquid or semi-solid food for precise dosing. 3

Monitoring Requirements

Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases. 1, 2 At each visit, assess for:

• Withdrawal symptoms: Anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion 1, 2
• Seizure risk: Abrupt discontinuation can cause seizures and death—never stop suddenly 1, 2, 3
• Functional status: Ability to maintain daily activities 1
• Mood changes: Depression, panic attacks, suicidal ideation 1

Managing Withdrawal Symptoms

If withdrawal symptoms become severe at any reduction, return to the previous well-tolerated dose and pause the taper for 2–4 weeks before attempting a smaller reduction (5% instead of 10%). 1, 2

Adjunctive Medications for Symptom Management

• For insomnia: Trazodone 25–50mg at bedtime (short-term) 1, 2
• For anxiety: Gabapentin 100–300mg at bedtime or three times daily, titrated by 100–300mg every 1–7 days as tolerated 1
• For autonomic symptoms: Clonidine or tizanidine 2

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar dependence risks. 1

Non-Pharmacologic Support

Integrating cognitive-behavioral therapy for insomnia (CBT-I) during the taper significantly increases success rates and should be offered alongside the medication taper. 1, 4, 2 CBT-I provides superior long-term efficacy compared with medications and preserves benefits after drug discontinuation. 1

Additional supportive measures include:

• Sleep hygiene education 1, 2
• Relaxation techniques and mindfulness 1, 2
• Exercise and fitness training 1, 2

When to Refer to a Specialist

Immediate specialist referral is indicated for: 1, 2

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts
• Pregnancy (withdrawal can cause spontaneous abortion and premature labor) 1, 2

Critical Pitfalls to Avoid

Never taper too quickly: Reductions faster than 10% every 2 weeks (or 10% per month for long-term users) significantly increase withdrawal symptoms and taper failure. 1, 2

Never use straight-line reductions from the starting dose: Always calculate the 10% reduction from the current dose, not the original 0.5mg dose, to prevent disproportionately large final decrements. 1, 2

Never abandon the patient: If tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance at a reduced dose rather than complete discontinuation. 1, 2 The CDC explicitly notes that the target dose does not need to be zero. 1, 2

Never set arbitrary time limits: 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, 4, 2

Realistic Timeline and Goals

The taper will likely require a minimum of 3–6 months for short-term users (<1 year) and 10–12 months or longer for long-term users (≥1 year). 1, 2 Some patients may require several years to complete the taper safely. 1

Patient agreement and interest in tapering is a key component of success. 1, 2 Use shared decision-making and explain the risks of continued use (cognitive impairment, falls, dependence) versus benefits of discontinuation (improved psychomotor and cognitive functioning, particularly memory and daytime alertness). 1, 5

Expected Outcomes

Research demonstrates that when clonazepam (a similar benzodiazepine) is tapered gradually at 0.25mg per week after intermediate-term use, 68.9% of patients successfully discontinue within 4 months, with an additional 26% requiring 3 more months. 5 Withdrawal symptoms are mostly mild and include anxiety, tremor, nausea, insomnia, sweating, tachycardia, headache, weakness, and muscle aches. 5 Improvement in general well-being is maintained during both the taper and follow-up phases. 5