In a 67-year-old woman with schizophrenia taking lorazepam 1 mg as needed twice daily, temazepam 15 mg nightly, olanzapine‑samidorphan (LYBALVI) 20/10 mg, and gabapentin 300 mg three times daily, which medication should be tapered first?

Taper Lorazepam First in This 67-Year-Old Woman with Schizophrenia

In this 67-year-old woman taking multiple psychotropic medications, lorazepam should be tapered first because it is the adjunctive medication with the highest risk profile in elderly patients and is not treating the primary disorder (schizophrenia). The olanzapine-samidorphan (LYBALVI) must be maintained as the core antipsychotic for schizophrenia, while the benzodiazepines (lorazepam and temazepam) carry substantial risks of cognitive impairment, falls, fractures, and functional decline in older adults 1.

Rationale for Tapering Lorazepam First

Application of Polypharmacy Reduction Principles

The general framework for medication discontinuation prioritizes removing adjunctive medications before core treatments for the primary disorder 2. In this case:

• Olanzapine-samidorphan (LYBALVI) 20-10mg is the primary treatment for schizophrenia and must be maintained 2
• Lorazepam 1mg PRN BID is an adjunctive anxiolytic, not essential for schizophrenia management 2
• Temazepam 15mg is treating insomnia, a secondary symptom 2
• Gabapentin 300mg TID may be providing mood stabilization or anxiety management 1

Age-Specific Safety Concerns with Benzodiazepines

The American Geriatrics Society Beers Criteria explicitly recommend avoiding all benzodiazepines in adults ≥65 years due to increased sensitivity and substantial risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes 1. This patient is 67 years old, placing her squarely in the high-risk category.

Specific risks in elderly patients include 1:

• Cognitive impairment and accelerated cognitive decline
• Reduced mobility and unsafe driving
• Loss of functional independence
• Falls and fractures
• Increased mortality risk

Why Lorazepam Before Temazepam

Lorazepam should be tapered before temazepam because:

1. PRN dosing pattern: Lorazepam is dosed "as needed" twice daily, suggesting it may not be used consistently and therefore may be easier to discontinue 1

2. Daytime benzodiazepine exposure: Lorazepam provides daytime sedation and cognitive impairment risk, whereas temazepam is confined to nighttime use 1, 3

3. Functional impact: Daytime benzodiazepines have greater impact on falls, driving safety, and daily activities compared to bedtime-only hypnotics 1

4. Evidence for temazepam safety: Research specifically in elderly patients (ages 69-98) showed temazepam 7.5-10mg can be discontinued without rebound insomnia 4, 5, and adverse effects are infrequent (7.8% incidence) and mild 6

Recommended Tapering Protocol for Lorazepam

Taper Schedule

Reduce lorazepam by 10% of the current dose per month for patients on benzodiazepines longer than one year 1. If duration is less than one year, reduce by 10-25% of the current dose every 1-2 weeks 1.

For lorazepam 1mg PRN BID (maximum 2mg/day):

• Month 1: Reduce to 0.9mg PRN BID (10% reduction) 1
• Month 2: Reduce to 0.8mg PRN BID (10% of current dose) 1
• Month 3: Reduce to 0.7mg PRN BID 1
• Continue this pattern until complete discontinuation

Critical safety warning: The reduction must be a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 1.

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion 1
• Screen for depression, anxiety worsening, and suicidal ideation 1
• Assess for falls, cognitive changes, and functional status 1

When to Pause or Slow the Taper

Clinically significant withdrawal symptoms signal the need to slow the taper rate or pause entirely 1. Acceptable reasons to pause for 2-4 weeks include 1:

• Severe anxiety or panic attacks
• Functional decline affecting daily activities
• Emergence of depression or suicidal ideation
• Physical withdrawal symptoms (tremor, tachycardia, sweating)

Adjunctive Strategies to Improve Success

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated 1. Additional supportive measures include 1:

• Mindfulness and relaxation techniques
• Sleep hygiene education
• Exercise and fitness training
• Patient education about benzodiazepine risks

Gabapentin is already prescribed at 300mg TID and can help mitigate withdrawal symptoms 7, 1. This existing medication provides pharmacological support during the lorazepam taper without adding new agents 7.

Subsequent Medication Management

After Lorazepam Discontinuation: Taper Temazepam Second

Once lorazepam is successfully discontinued, temazepam should be the next medication tapered 1. The same gradual reduction principles apply:

• Reduce by 10% of the current dose per month for long-term use 1
• Monitor for rebound insomnia (though research shows this is uncommon in elderly patients at doses ≤15mg) 4, 5
• Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks 1

For insomnia management after temazepam discontinuation, consider 1:

• First-line: Cognitive-behavioral therapy for insomnia (CBT-I)
• Pharmacologic alternative: Low-dose doxepin 3-6mg at bedtime (preferred for elderly patients with sleep-maintenance insomnia)
• Avoid: Trazodone is not recommended for insomnia in older adults (only 10-minute reduction in sleep latency, 75% adverse event rate) 1

Maintain Core Medications

Olanzapine-samidorphan (LYBALVI) 20-10mg must be continued as the primary treatment for schizophrenia 2, 8, 9. This combination provides effective antipsychotic treatment while mitigating olanzapine's metabolic side effects through samidorphan's opioid receptor antagonism 9.

Gabapentin 300mg TID should be maintained during benzodiazepine tapering as it provides adjunctive support for withdrawal symptoms and may be treating underlying anxiety or mood symptoms 7, 1.

Critical Safety Warnings

1. Never stop benzodiazepines abruptly: Abrupt discontinuation can cause seizures and death 7, 1

2. Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually 7, 1

3. The taper rate must be determined by the patient's tolerance, not a rigid schedule, and pauses are acceptable and often necessary 7, 1

4. Expected timeline: The complete benzodiazepine taper will likely require 6-12 months minimum, possibly longer 1

5. Maintenance therapy is acceptable: If the patient cannot complete tapering, maintaining a reduced dose is a legitimate outcome 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

Summary Algorithm

1. Taper lorazepam first (adjunctive anxiolytic with highest elderly risk profile)
2. Then taper temazepam (adjunctive hypnotic, secondary symptom)
3. Maintain olanzapine-samidorphan (primary schizophrenia treatment)
4. Maintain gabapentin (supports withdrawal, may treat underlying symptoms)
5. Use 10% monthly dose reductions with monthly monitoring
6. Integrate CBT to improve success rates
7. Pause taper if significant withdrawal emerges
8. Plan for 6-12+ month timeline for complete benzodiazepine discontinuation