Strategies For Tapering Off Ativan (Lorazepam)

Carol asked

I would like to know how to taper off lorazepam. I have been taking 1 to 2 milligrams for about 2 1/2 months.

Answer

Ativan (lorazepam) belongs to a class of drugs known as 'benzodiazepines'. Although benzodiazepines are effective in treating a range of indications (e.g. seizures and anxiety disorders), they are notoriously difficult to get off of, especially if you have been taking them for a long time.

Nevertheless, there are several strategies to help you lessen the risk and severity of side effects when it is time to discontinue them.

Below, I discuss the potential side effects you may experience while discontinuing Ativan and several methods that have been proposed to help you do so safely.

Ativan Withdrawal Side Effects

• Rebound of the condition being treated
• Sweating
• Increased heart rate
• Cramping
• Insomnia
• Muscle twitching
• Anxiety
• Numbness
• Agitation
• Diarrhea
• Nausea
• Dizziness
• Ringing in the ears
• Confusion
• Vomiting
• Seizures

Withdrawal symptoms of Ativan are generally worse if it is stopped abruptly (i.e cold-turkey). Therefore, a gradual withdrawal (i.e. taper) is recommended.

Additionally, some benzodiazepines are more likely than others to cause significant withdrawal symptoms. These include ones that are rapid-acting and have a short duration of action. Ativan does have a rapid onset of action and is relatively short-acting. This makes Ativan one of the benzodiazepines most commonly associated with negative withdrawal effects.

In fact, the prescribing information for Ativan notes that withdrawal symptoms have been noticed in individuals taking the drug for as little as one week:

"Withdrawal symptoms (e.g., rebound insomnia) can appear following cessation of recommended doses after as little as one week of therapy."

Strategies To Stopping Ativan

It is important to note that there is no single 'set-in-stone' recommendation to safely discontinue Ativan. The process will be individualized and be based on several factors, including:

• How long you have been taking Ativan (the longer you have been taking the drug, the more likely you are to have withdrawal effects)
• The condition being treated (if you are treating epilepsy, for example, stopping Ativan too quickly could precipitate withdrawal seizures)

Be sure to speak with your doctor regarding how to best taper and discontinue Ativan for your specific medical situation. What follows are some suggested strategies from a variety of studies and review articles on the matter.

Strategy One: Weekly Dose Decrease

Most studies recommend a 'general' taper, by decreasing your dose by 10-25% every week. This means it could take several months to completely stop Ativan.

Again, there are several factors that need to be taken into account when determining the length of your taper as some conditions may require longer periods of time.

For example, the American Psychiatric Association, in their 'Practice Guideline for the Treatment of Patients with Panic Disorder', recommend tapering no faster than 10% of your dose per week if treating panic disorder. Faster tapers may significantly increase the risk of rebound panic attacks.

Strategy Two: Use Liquid

As a general rule of thumb, it is better to reduce the dose of Ativan when tapering as opposed to decreasing the dosage interval. For example, if you are taking 2mg of Ativan every 6 hours, when tapering, decrease the strength of Ativan, but keep dosing every 6 hours. This helps to avoid in-between dose withdrawal.

Since it can be difficult to decrease a solid dosage form (like a tablet) by a small percentage (e.g. 10%) on a weekly basis, you may consider using Ativan liquid. Although you would follow the same tapering schedule as if you were taking tablets (e.g. 10-25% dose decrease every week), using liquid allows for greater flexibility and ease in dosing. Ativan is available as a 2mg/mL solution.

Strategy Three: Switch To A Long-Acting Benzodiazepine

It is generally agreed that the risk of withdrawal symptoms is greater with benzodiazepines that have a short duration of action. Xanax is perhaps the most notorious for being difficult to discontinue since it lasts such a short time in the body, precipitating withdrawal more quickly.

Therefore, it has been suggested that switching from a short half-life drug (like Xanax or Ativan) to one with a long half-life, such as clonazepam or Valium, and then tapering, could reduce withdrawal reactions in-between doses.

In fact, the World Health Organization's (WHO) 'Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Setting' has a blanket recommendation when it comes to benzodiazepine tapering, which is to switch to Valium (diazepam), then proceed with a taper.

The WHO has a 'diazepam equivalent chart' to help you convert doses if you and your doctor decide to switch. For Ativan, a dose of 0.5mg per day would be equivalent to a 5mg dose of diazepam per day.

Additional Information

Once you and your doctor decide on a tapering schedule, there is always room for adjustment. If you are experiencing moderate to severe withdrawal symptoms, it would be prudent to slow how quickly you are tapering down.

Some sources state that if withdrawal symptoms are particularly bad, you could theoretically return to your last well-tolerated dose and resume your taper in a more conservative manner. However, other sources, including the World Health Organization, does not recommend increasing your dose after starting a taper. They state: