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Benzodiazepine Tapering Flow Sheet

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Consider Benzodiazepine taper for patients with aberrant behaviors, behavioral risk factors, impairment or concurrent opioid use.

  1. Frame the conversation around tapering as a safety issue.
  2. Determine rate of taper based on degree of risk.
  3. If multiple drugs are involved, taper one at a time (e.g., start with opioids, follow with Benzodiazepines (BZPs).
  4. Set a date to begin and set a reasonable date for completion. Provide information to the patient and establish behavioral supports prior to instituting the taper. See OPG guidelines.

Benzodiazepine Taper
Basic principle: Expect anxiety, insomnia, and resistance. Patient education and support will be critical. Risk of seizures with abrupt withdrawal increases with higher doses. The slower the taper, the better tolerated.

Slow taper Rapid Taper

1. Calculate the total daily dose. Switch from short-acting agent (Alprazolam, Lorazepam) to longer-acting agent (Diazepam, Clonazepam, Chlordiazepoxide or Phenobarital). Upon initiation of taper, reduce the calculated dose by 25-50% to adjust for possible metabolic variance.

1. Pre-medicate two weeks prior to taper with Valproate 500mg BID or Carbamazepine 200mg every AM and 400mg every HS. Continue this medication for four weeks post-BZPs. Follow the usual safeguards (lab testing and blood levels) when prescribing these medications.

2. Schedule first follow-up visit two to four days after initiating taper to determine if adjustment in initial calculated dose is needed.

2. Utilize concomitant behavioral supports.

3. Reduce total daily dose by 5-10% per week in divided doses.

3. Discontinue current Benzodiazepine treatment and switch to Diazepam 2mg BID for two days, followed by 2mg every day for two days, then stop. For high doses, begin with 5mg BID for two days and then continue as described.

4. After ¼ to ½ of the dose is reached, you can slow the taper with cooperative patient.

4. Use adjuvant medications as mentioned above for rebound anxiety and other symptoms.

5. With cooperative patients who are having difficulty with this taper regimen, you can extend the total time of reduction to as much as six months.


6. Consider adjunctive agents to help with symptoms: Trazodone, Hydroxyzine, neuroleptics, anti-depressants, Clonidine and alpha-blocking agents.


Drug Half-life (hours) Dose Equivalent

Chlorodiazepoxide (Librium)

5-30 h

25mg

Diazepam (Valium)

20-50 h

10mg

Alprazolam (Xanax)

6-20 h

0.5mg

Clonazepam (Klonopin)

18-39 h

0.5mg

Lorazepam (Ativan)

10-20 h

1mg

Oxazepam (Serax)

3-21 h

15 mg

Triazolam (Halcion)

1.6-5.5 h

0.5mg

Phenobarbital (barbiturate)

53-118 h

30 mg