Benzodiazepine Equivalents – Clinical Questions to Consider

I came across this useful table of benzodiazepine equivalents and decided to share it with you.  Converting one drug to another always comes with challenges and benzodiazepines are no different.  It’s not always easy to know exactly what to do or how to convert from one benzodiazepine to another, but I put together a list of clinical questions to consider when weighing your options.

  1. Is the patient at a relatively low dose currently.  If so, then conversion should be fairly easy.  If the current dose is close to the usual initial dose, I’d likely recommend simply discontinuing and starting the other benzodiazepine at the usual starting dose.
  2. When we are converting benzodiazepines, it is important to understand what was wrong with the initial drug.  Was there side effects, ineffectiveness or another reason why.  This may sway your recommendation to convert to a similar class or go in a new direction.
  3. Is there a non-benzo alternative?  Benzodiazepines are not the safest drugs on the planet by any stretch of the imagination.  This is especially true in patient who may have historically had troubles with addiction or in our elderly population.
  4. What’s the indication?  I have seen a case of benzo withdrawal potentially causing a seizure.  Looking at the entire medical history and what the benzodiazepine is for is very important.  This may dictate how accurate you need to be in your conversion.
  5. Kinetic differences.  Understand that in the elderly in particular, half-lives can vary greatly from one benzo to the next, so the benzodiazepine equivalents chart as above may not tell the whole story and should be used with a grain of salt.  Diazepam vs. lorazepam is a classic example where half-life may be way different in the elderly than in a younger person.
  6. Is the provider looking to increase the dose? This may sway you on how aggressively to convert the benzo.
  7. How high is the dose? For any doses above the usual standard initial doses for benzodiazepines, I’m typically going to recommend a cross taper to try to minimize the kinetic differences encountered.

 

4 Comments

  1. Ray Collins

    How to you think this information and the table in the link might be used for withdrawing alprazolam via the temporary use of clonazepam? I don’t personally know anyone who has done this, but I gather from what I have read that this method helps some people.

    Reply
    • Cole

      I found this paper to be most helpful (published after your comment, naturally) https://www.ncbi.nlm.nih.gov/pubmed/28777203
      I’ve had anecdotal success with phenobarb for Xanax withdrawal, but I work in the ED so that may not be the safest modality for long-term management.

      Reply
  2. Patty Poczciwinski

    Thanks for the handy table Eric!

    Reply
  3. Mustafs

    This helpful. Thank you.

    Reply

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Written By Eric Christianson

May 28, 2017

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