Tapering Benzodiazepines

This is adapted from Primary Care RAP (HippoEd).  The podcast also mentioned the useful pearl that in one study of using a written letter outlining the concerns about BDZs, a significant portion of patient’s will self-taper!

  • So how do you do the taper?

    • Included a group of 180 people who were switched from lorazepam to daily diazepam (1mg = 10mg) and then reduced by 25% a week during 4 weekly visits. Adding CBT to tapering did not seem to make a difference.

      • Voshaar RC et. al. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial. Br J Psychiatry. 2003 Jun;182:498-504.  PMID: 12777340

    • Daily dose can be reduced by 25% in the first and second week and then the remaining 50% tapered off in 4 steps of 12.5% each in weeks three and four

      • Rickels K et. al. Pharmacologic strategies for discontinuing benzodiazepine treatment. J Clin Psychopharmacol. 1999 Dec;19(6 Suppl 2):12S-16S. Review. PMID: 10587279

    • Individuals from another study on chronic diazepam for insomnia proposed schedule of 25% reduction at 1-2 week intervals and then at each visit having physician look for signs of withdrawal (feeling anxious, not being able to sleep) and then reducing or lowering the dose depending on patient symptoms

      • Baillargeon L et. al. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ. 2003 Nov 11;169(10):1015-20. PMID: 14609970

    • Consistent across these studies was transition to diazepam, which has a longer half-life and usually takes 2-4 weeks for the metabolites to reach a steady state.

    • “The rate of withdrawal is the most contentious and least researched issue. The early stages of withdrawal are easier to tolerate than the later and last stages. The optimal duration is not clear and may indeed vary patient to patient.”  Likely brisk schedule of 8-12 weeks or even faster is preferred because if withdrawal goes on for too long, it becomes the focus of the patient’s existence. Those that have failed likely will need up to 6 months the second time around.

      • Lader M et. al. Withdrawing benzodiazepines in primary care. CNS Drugs. 2009;23(1):19-34.  PMID: 19062773

    • Summary: Go as fast as the patient can tolerate with at least once weekly visits and lots of support!

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