{"id":2097,"date":"2018-05-29T13:34:39","date_gmt":"2018-05-29T20:34:39","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2097"},"modified":"2018-05-29T13:34:39","modified_gmt":"2018-05-29T20:34:39","slug":"benzodiazepine-tapering","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2097","title":{"rendered":"Benzodiazepine Tapering"},"content":{"rendered":"

By James J. Cotter, MD, MPH, Regional Medical Director<\/strong><\/p>\n

Benzodiazepine Tapering<\/strong><\/p>\n

Benzodiazepines are one of the most used psychotropic medications in the US. Although the indications for short term use<\/em> include anxiety or sleep disturbances, many adults are prescribed benzodiazepines for years to decades despite warnings against long term use. Side effects of benzodiazepines include sedation and lethargy, impaired cognition and memory, dependency and abuse and increased risk of falls in older adults.\u00a0 Alcohol increases the risks of side effects as does co-prescription with opioid medications.<\/p>\n

Long term use of benzodiazepines is problematic and the significant risks of long term use outweigh any potential (and poorly proven) benefits.\u00a0 If benzodiazepines are to be used long term, it is preferable to avoid short acting agents and to use the lowest effective dose.\u00a0 Some benzodiazepines, such as alprazolam, appear more associated with misuse and should be avoided. \u00a0Patients using short acting benzodiazepines may increase the dose and frequency due to anxiety or restlessness between doses or difficulty sleeping at night. Warning signs for abuse or diversion include escalating dose or frequency, deteriorating function, \u201clost\u201d pills, or other evidence suggesting misuse of the drug. \u00a0The risk of dependency and abuse is particularly worrisome on opioids and those individuals with a history of substance use disorders.<\/p>\n

In some cases, the patient may notice decreased cognitive function or begin having falls and then ask for help in tapering off the benzodiazepine.\u00a0 One should definitely consider tapering benzodiazepines for your patients who are over 65 years of age, are taking multiple benzodiazepines, or those who have cognitive difficulties and patients with substance or alcohol use disorder.<\/p>\n

Outpatient Tapering<\/strong><\/p>\n

Once the decision to taper has been made, what methods work best to safely and effectively taper?\u00a0 Assuming this is an outpatient setting and there is no evidence of drug abuse or diversion, there are many algorithms for the safe tapering of benzodiazepines. For patients under 65 years of age, most algorithms recommend switching to a long acting benzodiazepine, such as diazepam.\u00a0 When switching to diazepam, choose a dose equivalent to the short acting agent\u2019s dose.\u00a0 However, the starting dose of diazepam should not exceed 40 mg daily.\u00a0 In older patients, the safest options are lorazepam or temazepam since they do not have active metabolites.<\/p>\n\n\n\n\n\n\n\n\n\n
Drug<\/strong><\/td>\n\n

Half Life\u00a0<\/strong>(hours)<\/strong><\/p>\n<\/td>\n

\n

Active Metabolites<\/strong><\/p>\n<\/td>\n

Dose equivalent to\u00a0<\/strong>5 mg diazepam<\/strong><\/td>\n<\/tr>\n
Oxazepam<\/td>\n5-15<\/td>\nnone<\/td>\n15 mg<\/td>\n<\/tr>\n
Temazepam<\/td>\n8-15<\/td>\nnone<\/td>\n10 mg<\/td>\n<\/tr>\n
Lorazepam<\/td>\n10-20<\/td>\nnone<\/td>\n1 mg<\/td>\n<\/tr>\n
Alprazolam<\/td>\n6-26<\/td>\nnone<\/td>\n0.5 mg<\/td>\n<\/tr>\n
Clonazepam<\/td>\n18-50<\/td>\nnone<\/td>\n0.5 mg<\/td>\n<\/tr>\n
Diazepam<\/td>\n20-80<\/td>\nseveral<\/td>\n5 mg<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

If the patient is on a high dose of benzodiazepines (over 40 mg of diazepam or equivalent), it may be possible to initially reduce the dose by as much as 25% and then continue decreasing the dose by 10% per week.\u00a0 Usual therapeutic doses may begin tapering at 10% per week.\u00a0 Side effects of tapering include anxiety and restlessness, agitation, tremors and panic attacks.\u00a0 Long term withdrawal symptoms may include anxiety, confusion, depression and cognition\/memory symptoms.\u00a0 Anxiety-related withdrawal symptoms may be mitigated by beginning cognitive behavioral therapy, SSRIs, TCAs or buspirone prior to tapering the benzodiazepine.\u00a0 Insomnia can be \u201cpre-treated\u201d by cognitive behavioral therapy, TCAs and sleep hygiene education.<\/p>\n

For patients with a history of seizures or current active drug use, assistance from an addiction specialist may be necessary.\u00a0 Patients with severe mood disorders or suicidality may require psychiatric consultation.<\/p>\n

A standardized office based approach to dose reduction of benzodiazepines can be very successful. Studies have shown success achieving complete withdrawal in about half of patients on benzodiazepines and a significant dose reduction in another quarter of benzodiazepine patients. The factors indicating the highest likelihood of success are:\u00a0 a caring clinician, current use of benzodiazepines at a diazepam dose equivalent to 10 mg or less and patients without underlying depression.<\/p>\n

Summary:<\/strong><\/p>\n