141 - Pattern of tapering

Pattern of tapering

468 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Practical application of these principles Before tapering ■ ■All patients should be informed of the risk of withdrawal symptoms on stopping any benzodiazepine, z-­drug or gabapentinoid. ■ ■The patient should be warned not to stop benzodiazepines abruptly, because this can cause seizures and can be fatal, and may be the method most likely to give rise to severe and long-­lasting withdrawal symptoms. ■ ■Although stopping benzodiazepines can cause unpleasant symptoms, if tapering is gradual and careful the process can be tolerable. Reassurance may be required for those that have rapidly tapered in the past. ■ ■Most long-­term users take months or years to taper. However, rate of reduction should be determined by what is tolerable for the patient, not externally imposed timetables. ■ ■Preparation for benzodiazepine tapering may be required (e.g. lightening work or family duties or bolstering of non-­pharmacological coping skills).32,38 ■ ■Gradual dose reduction is the most evidenced approach to cessation, with weaker evidence for adjunctive psychological interventions (relaxation, CBT).33 ■ ■Familiarity with the wide variety of withdrawal symptoms may help to mitigate unnecessary anxiety when symptoms arise. The process of tapering ■ ■Reductions in dosing for patients may be broadly risk stratified: ■ ■for low-­risk patients (<6 months’ use, long half-­life benzodiazepine, no experience of significant withdrawal in the past), a test reduction could be made of 10–20% ■ ■for high-­risk patients (>6 months use, short half-­life benzodiazepine, past history of withdrawal symptoms), a test reduction of 5–10% could be recommended. ■ ■Reductions should be made according to a proportion (e.g. 10%) of the last dose. This means that the reductions recommended will become smaller and smaller as the total dose is lowered. Most long-­term users will be able to proceed between a rate of about 5–10% of their most recent dose per month (or perhaps more quickly). ■ ■After reduction withdrawal symptoms should be monitored for 2–4 weeks, or until symptoms have resolved. Monitoring may take the form of simple measures of symptoms each day (e.g. out of 10) or using standardised benzodiazepine withdrawal scales. ■ ■Further reduction should be titrated to the tolerability of this experience. Troubleshooting ■ ■If significant withdrawal symptoms emerge at any point, either hold the current dose to allow symptoms to resolve or, if that is intolerable, increase to the last dose at which the symptoms were tolerable and remain there until symptoms resolve. After stabilisation, tapering will need to be more gradual, with reductions being made in smaller amounts. ■ ■The experience of distressing withdrawal symptoms does not necessarily indicate that a patient cannot stop benzodiazepines but that they will need to taper more slowly,