Can Buspirone Be Added During Benzodiazepine Taper in a 73-Year-Old?
Yes, buspirone can be safely added to this 73-year-old patient tapering clonazepam 0.5 mg daily, though the evidence for its efficacy in facilitating benzodiazepine discontinuation is mixed and generally weak. 1, 2
Safety Profile in Elderly Patients
Buspirone is safe for use in geriatric patients, with FDA labeling indicating that safety and efficacy profiles in 605 elderly patients (mean age 70.8 years) were similar to younger populations, and no age-related pharmacokinetic differences were observed. 1
No dose adjustment is required based on age alone, though starting at lower doses and observing closely is recommended per general geriatric prescribing principles. 1
Buspirone does not share cross-tolerance with benzodiazepines, meaning it will not suppress benzodiazepine withdrawal symptoms through the same GABA-ergic mechanisms. 3
Evidence for Efficacy During Benzodiazepine Taper
The evidence regarding buspirone's effectiveness in facilitating benzodiazepine discontinuation is contradictory:
Potentially Supportive Evidence:
One study showed a non-significant trend toward higher taper success with buspirone (67.9%) compared to placebo (37.5%), though this did not reach statistical significance. 4
Buspirone may reduce anxiety levels during taper, with one study showing significantly lower anxiety in buspirone-treated patients compared to placebo during alprazolam withdrawal. 5
Buspirone significantly reduced abstinence symptoms (as measured by the Abstinence Rating Scale) when used concurrently during alprazolam tapering. 5
Negative or Neutral Evidence:
A 2018 Cochrane systematic review found insufficient evidence to support pharmacological interventions (including buspirone) for benzodiazepine discontinuation, with all evidence rated as low or very low quality. 6
Multiple studies showed no benefit: One trial found buspirone did not help alleviate benzodiazepine withdrawal symptoms and had a markedly higher dropout rate (7/11) compared to placebo (1/12). 7
Another study found no difference in discontinuation severity or taper-free status at 12 weeks between buspirone, imipramine, and placebo groups. 8
A 1987 study concluded buspirone does not suppress benzodiazepine withdrawal symptoms and does not materially assist withdrawal. 3
Practical Considerations for This Patient
Dosing Strategy:
Start buspirone at 5 mg three times daily (15 mg/day total), which can be increased gradually to a target of 20-30 mg/day if needed. 1, 5
Begin buspirone 2-4 weeks before starting the clonazepam taper to allow time for anxiolytic effects to develop, as buspirone requires several weeks to reach full efficacy. 4, 5
Clonazepam Taper Protocol:
For this low dose (0.5 mg daily), reduce by 0.25 mg every 1-2 weeks, as clonazepam can be successfully discontinued without major withdrawal symptoms if reduced gradually. 9
The 2025 joint clinical practice guideline emphasizes not discontinuing benzodiazepines abruptly in physically dependent patients, using shared decision-making, and tailoring tapering strategies to individual patient response. 2
Monitoring:
Watch for common buspirone side effects including dizziness, nausea, headache, and nervousness, though these are generally mild. 1
Monitor for clonazepam withdrawal symptoms including anxiety, tremor, insomnia, sweating, and palpitations, which are typically mild with gradual taper. 9
Assess hepatic and renal function, as buspirone is contraindicated in severe hepatic or renal impairment due to increased plasma levels and prolonged half-life. 1
Clinical Bottom Line
Adding buspirone is a reasonable adjunctive strategy given its safety profile in elderly patients and potential (though inconsistent) benefit in reducing anxiety during benzodiazepine taper. 1, 4, 5 However, the most critical factor for successful taper is the gradual dose reduction schedule itself, not the addition of buspirone. 2, 6, 9 The 2019 AGS Beers Criteria strongly recommends tapering benzodiazepines in older adults due to risks of sedation, cognitive impairment, falls, and dependence. 10
If buspirone is added, set realistic expectations with the patient that it may help with anxiety symptoms but will not eliminate withdrawal symptoms entirely, and success depends primarily on slow, individualized tapering. 2, 6