Tapering Benzodiazepines – Tricks of the Trade
Tapering benzodiazepines or any drug for that matter is a bit of an art. Sure we do have some evidence on these types of topics, but we can’t also schedule a taper schedule perfectly based upon a percentage of the dose. Dosage forms and the patients themselves can throw a wrinkle into what we might think is a perfect plan.
Tapering Benzodiazepines – What’s the Evidence Say?
Most evidence for dose reductions of benzodiazepines will fall in the 10-25%. This is pretty well in line with tapering opioids. What you do have to remember with benzodiazepines is that withdrawal has a much higher likelihood of being life-threatening when compared to opioids. Here’s an article discussing benzodiazepine tapering.
Factors to Consider
Half-life, patient readiness/willingness, past history, and dosage form(s) are major factors that may have an impact on forming a benzodiazepine tapering schedule.
With half-life, it is important to know which benzodiazepine you are dealing with. Diazepam, for example, has a very long half-life. Tapering tends to be a little easier for drugs with a longer half-life. Triazolam is an example of a benzodiazepine that has a very short half-life. Many of the most commonly used benzodiazepines like lorazepam, clonazepam, and alprazolam have more intermediate half-lives (i.e. 6-30 hours or so…). Here’s a table to refresh yourself with benzodiazepine half-lives. In addition, a longer half-life drug may be more likely to allow you to get away with alternate-day dosing as you are trying to taper a patient down.
If patients are ready and willing for reductions, you may be able to get a little more aggressive with early reductions. Tapering tends to get more difficult as patients get to lower and lower dosages. If patients are scared or worried about reducing but know that they should, being a little more cautious may be the best approach to allow that patient to gain confidence that they can reduce their medication burden. Here’s some good information for patients that you should check out. It also gives a sample taper schedule.
Do not forget to recognize how long a patient has been receiving a benzodiazepine. In general, higher doses, and a longer period of benzodiazepine use will make tapering more difficult.
Available dosage forms can make things more challenging. We may end up doing a larger reduction that we would like if there are dosage form issues. Most benzodiazepines are immediate-release tablets which means that many can be split without issues. This can make taper schedules much easier.
Figuring out intervals of reduction can also be difficult. Many will target 2-4 week intervals as the initial timeframe for reduction. Work with your patient to see what is reasonable for follow up and how often we can reduce the dose. If reducing more frequently like every week, then we might consider doing a lower % reduction.
Lastly, because tapering benzodiazepines can be challenging, it is important to adapt to the information that your patient is providing when beginning to taper medications. It is ultimately their health and discomfort we are trying to help them with. Putting them in the driver seat and sharing our goal of continued progress to a safer, lower dose or potentially off medication with significant adverse effects is critical to success.
Have you had experience tapering benzodiazepines? Leave a comment below!
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