Benzodiazepine Withdrawal

Aka: Benzodiazepine Withdrawal, Benzodiazepine Taper Schedule

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II. Indications

  1. Benzodiazepine Abuse
  2. Benzodiazepine Dependence
    1. Age over 65 years
    2. Benzodiazepine use >4 weeks (dependence may start within days of regular use)

III. Symptoms: Acute

  1. Common
    1. Anxiety
    2. Irritability
    3. Insomnia
    4. Myalgias
    5. Tremor
    6. Diaphoresis
    7. Gastrointestinal findings (e.g. Nausea, Diarrhea)
  2. Severe
    1. Seizures
    2. Delirium Tremens
    3. Depression with Suicidality
    4. Psychosis
    5. Catatonia

IV. Symptoms: Chronic (up to 12 months after stopping)

  1. Depressed Mood
  2. Cognitive Impairment
  3. Insomnia
  4. Anxiety
  5. Motor symptoms
  6. Paresthesias
  7. Tinnitus

V. Management: Benzodiazepine Taper Schedules

  1. Monitor every 1 to 2 weeks
  2. Calculate Diazepam to Benzodiazepine Equivalents
    1. See Benzodiazepine Equivalents
    2. Convert from short acting (e.g, Alprazolam) to long acting Benzodiazepines (e.g. Diazepam) at start of taper
  3. Protocol: Typical for on longterm prescribed Benzodiazepines
    1. Start at 50% of calculated Valium dose
    2. Reduce dose by 25% each week for the first 2 weeks, until 50%, then decrease dose by 12.5% every 4-7 days
    3. Decrease dose by no more than 5 mg Diazepam equivalents/week until <20 mg/week, then decrease by 1-2 mg/week
    4. Decrease Alprazolam by no more than 0.5 mg increments
      1. Alprazolam >=6 mg/day decrease by 0.5 mg every 2 to 3 weeks
      2. Alprazolam <= 2 mg/day decrease by 0.25 mg every 2 to 3 weeks
  4. Example: Rapid Taper for Detox in Benzodiazepine Abuse
    1. Alprazolam 6 mg is equivalent to 60 mg Diazepam
    2. Alprazolam 10 mg is equivalent to 100 mg Diazepam
    3. Start taper at 50% or 50 mg Diazepam per day
    4. Decrease dosing per Diazepam taper below
      1. Days 1-3: 10 mg orally three times daily (30 mg/day)
      2. Days 4-6: 5 mg orally four times daily (20 mg/day)
      3. Days 7-9: 5 mg orally three times daily (15 mg/day)
      4. Days 10-12: 5 mg orally twice daily (10 mg/day)
      5. Days 13-15: 5 mg orally daily (5 mg/day)
  5. Indications for slower taper (over 6 to 12 weeks)
    1. Alprazolam (esp. high dose >4 mg/day)
    2. Benzodiazepine use >2 to 3 months
    3. Seizure Disorder
    4. Panic Disorder
      1. Decrease dose by no more than 10% of dose weekly (typically over 2 to 7 months)
  6. Other adjunctive medications for Benzodiazepine Withdrawal symptoms
    1. Valproate
    2. Tricyclic Antidepressants
    3. Beandrup (2018) Cochrane Database Syst Rev (3): CD011481 [PubMed]

VI. References

  1. (2020) Presc Lett, Resource #361206, Appropriate Use of Benzodiazepines

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