Benzodiazepine Deprescribing
Diazepam-equivalent conversion (Table 3.7) + switch guidance
Lorazepam 2 mg ≈ diazepam 20 mg
Equivalence is approximate — These equivalencies are based on clinical experience and so may not be exact — they may need to be individualised based on withdrawal symptoms. There is no pharmacokinetically precise benzodiazepine conversion (unlike opioids or PPIs); published values vary between sources (e.g. lorazepam 1–2 mg per 10 mg diazepam). Switch step-wise, prioritise the patient's reported symptoms, and allow a period of stabilisation (~2 weeks or longer) on the new drug before starting a taper.
- Switch: Switch step-wise (not abruptly), prioritise the patient’s reported symptoms, and allow ~2 weeks of stabilisation on the new drug before tapering.
- Hepatic impairment: In significant hepatic impairment prefer lorazepam (no active metabolites, clearance unaffected by liver function); diazepam, clonazepam and chlordiazepoxide accumulate.
Diazepam-equivalent reference — Maudsley Table 3.7
| Drug | ≈ 10 mg diazepam | Half-life | Class |
|---|---|---|---|
| Alprazolam | 0.5 mg | 12–15 hours | benzodiazepine |
| Chlordiazepoxide | 25 mg | 8–28 hours | benzodiazepine |
| Clonazepam | 0.5 mg | 20–60 hours (mean 30 hours) | benzodiazepine |
| Clorazepate | 15 mg | 18–50 hours (1–8 days) | benzodiazepine |
| Diazepam | 10 mg | 24–48 hours (active metabolite up to 100 hours) | benzodiazepine |
| Estazolam | 1 mg (1–2 mg) | 10–24 hours | benzodiazepine |
| Eszopiclone | 3 mg | 6 hours | z-drug |
| Flurazepam | 20 mg (15–30 mg) | 40–114 hours | benzodiazepine |
| Lorazepam | 1 mg | 12 hours | benzodiazepine |
| Lormetazepam | 1 mg (1–2 mg) | 10–12 hours | benzodiazepine |
| Nitrazepam | 10 mg | 24 hours | benzodiazepine |
| Oxazepam | 20 mg | 6–20 hours | benzodiazepine |
| Quazepam | 20 mg | 39 hours (active metabolite 73 hours) | benzodiazepine |
| Temazepam | 20 mg | 7–11 hours (mean 8 hours) | benzodiazepine |
| Triazolam | 0.5 mg | 1.5–5 hours | benzodiazepine |
| Zaleplon | 20 mg | 1 hour | z-drug |
| Zolpidem | 20 mg | 0.7–3.5 hours (mean 2.4 hours) | z-drug |
| Zopiclone | 15 mg | 5 hours | z-drug |
Diazepam 10 mg is the anchor unit (the omeprazole-unit analog). Lorazepam is a secondary anchor preferred in hepatic impairment. Source: Horowitz & Taylor, The Maudsley Deprescribing Guidelines (2024), Table 3.7. Per-drug hyperbolic taper schedules are coming next.
Hyperbolic direct taper schedules (Maudsley Ch.3)
Diazepam — Moderate taper
up to 2.5 percentage points of GABA-A occupancy per step · reductions every 1–4 weeks · approx 44 steps
Dataset values not yet independently re-verified — confirm doses against the source.
| Date | Step | Dose | How | GABA-A % |
|---|---|---|---|---|
| 2026-08-20 | 1 | 60 mgAM 30 · PM 30 | Use tablets | 70.8% |
| 2026-09-03 | 2 | 56 mgAM 28 · PM 28 | Use tablets | 69.4% |
| 2026-09-17 | 3 | 52 mgAM 26 · PM 26 | Use tablets | 67.8% |
| 2026-10-01 | 4 | 48 mgAM 24 · PM 24 | Use tablets | 66% |
| 2026-10-15 | 5 | 44 mgAM 22 · PM 22 | Use tablets | 64% |
| 2026-10-29 | 6 | 40 mgAM 20 · PM 20 | Use tablets | 61.8% |
| 2026-11-12 | 7 | 38 mgAM 19 · PM 19 | Use tablets | 60.6% |
| 2026-11-26 | 8 | 36 mgAM 18 · PM 18 | Use tablets | 59.3% |
| 2026-12-10 | 9 | 34 mgAM 17 · PM 17 | Use tablets | 57.9% |
| 2026-12-24 | 10 | 32 mgAM 16 · PM 16 | Use tablets | 56.4% |
| 2027-01-07 | 11 | 30 mgAM 15 · PM 15 | Use tablets | 54.8% |
| 2027-01-21 | 12 | 28 mgAM 14 · PM 14 | Use tablets | 53.1% |
| 2027-02-04 | 13 | 26 mgAM 13 · PM 13 | Use tablets | 51.3% |
| 2027-02-18 | 14 | 24 mgAM 12 · PM 12 | Use tablets | 49.3% |
| 2027-03-04 | 15 | 22 mgAM 11 · PM 11 | Use tablets | 47.1% |
| 2027-03-18 | 16 | 20 mgAM 10 · PM 10 | Use tablets | 44.7% |
| 2027-04-01 | 17 | 19 mgAM 9.5 · PM 9.5 | Use ¼ tablets | 43.5% |
| 2027-04-15 | 18 | 18 mgAM 9 · PM 9 | Use tablets | 42.2% |
| 2027-04-29 | 19 | 17 mgAM 8.5 · PM 8.5 | Use ¼ tablets | 40.8% |
| 2027-05-13 | 20 | 16 mgAM 8 · PM 8 | Use tablets | 39.3% |
| 2027-05-27 | 21 | 15 mgAM 7.5 · PM 7.5 | Use ¼ tablets | 37.8% |
| 2027-06-10 | 22 | 14 mgAM 7 · PM 7 | Use tablets | 36.2% |
| 2027-06-24 | 23 | 13 mgAM 6.5 · PM 6.5 | Use ¼ tablets | 34.5% |
| 2027-07-08 | 24 | 12 mgAM 6 · PM 6 | Use tablets | 32.7% |
| 2027-07-22 | 25 | 11 mgAM 5.5 · PM 5.5 | Use ¼ tablets | 30.8% |
| 2027-08-05 | 26 | 10 mgAM 5 · PM 5 | Use tablets | 28.8% |
| 2027-08-19 | 27 | 9 mgAM 4.5 · PM 4.5 | Use ¼ tablets | 26.7% |
| 2027-09-02 | 28 | 8 mgAM 4 · PM 4 | Use tablets | 24.5% |
| 2027-09-16 | 29 | 7.5 mgAM 3.5 · PM 4 | Use ¼ tablets | 23.3% |
| 2027-09-30 | 30 | 7 mgAM 3.5 · PM 3.5 | Use ¼ tablets | 22.1% |
| 2027-10-14 | 31 | 6.5 mgAM 3 · PM 3.5 | Use ¼ tablets | 20.8% |
| 2027-10-28 | 32 | 6 mgAM 3 · PM 3 | Use ½ tablets | 19.5% |
| 2027-11-11 | 33 | 5.5 mgAM 2.5 · PM 3 | Use ¼ tablets | 18.2% |
| 2027-11-25 | 34 | 5 mgAM 2.5 · PM 2.5 | Use ¼ tablets | 16.8% |
| 2027-12-09 | 35 | 4.5 mgAM 2 · PM 2.5 | Use ¼ tablets | 15.4% |
| 2027-12-23 | 36 | 4 mgAM 2 · PM 2 | Use tablets | 13.9% |
| 2028-01-06 | 37 | 3.5 mgAM 1.5 · PM 2 | Use ¼ tablets | 12.4% |
| 2028-01-20 | 38 | 3 mgAM 1.5 · PM 1.5 | Use ¼ tablets | 10.8% |
| 2028-02-03 | 39 | 2.5 mgAM 1 · PM 1.5 | Use ¼ tablets | 9.2% |
| 2028-02-17 | 40 | 2 mgAM 1 · PM 1 | Use ½ tablets | 7.5% |
| 2028-03-02 | 41 | 1.5 mgAM 0.5 · PM 1 | Use ¼ tablets | 5.7% |
| 2028-03-16 | 42 | 1 mgAM 0.5 · PM 0.5 | Use ¼ tablets | 3.9% |
| 2028-03-30 | 43 | 0.5 mgAM 0 · PM 0.5 | Use ¼ tablets | 2% |
| 2028-04-13 | 44 | STOP | 0% |
Formulations
- Tablets: 2, 5, 10 mg — halve or quarter for intermediate doses
- Liquid: 2 mg/5 mL (0.4 mg/mL), 5 mg/5 mL (1 mg/mL), and 2 mg/mL oral solution
- Off-label for small doses: crushed-tablet suspension in water or full-fat milk (use immediately), or compounded tapering strips
Deprescribing notes
- Doses are split AM/PM (twice daily); the schedule shows both. Diazepam's long half-life makes once- or twice-daily dosing suitable during a taper.
- Make each reduction only after withdrawal symptoms from the previous one have largely resolved — aim for symptoms that are tolerable and settle within 1–2 weeks.
- Intermediate steps halfway between listed doses can be added; microtapering (small daily reductions) is an option for the low-dose tail.
- Skipping doses / every-other-day dosing is acceptable only for long-acting drugs like diazepam — avoid it for shorter-acting benzodiazepines.
Cautions
- Abrupt benzodiazepine discontinuation can precipitate severe withdrawal — including seizures, delirium and psychosis. Do not stop abruptly.
- These regimens are examples, not prescriptions — modify them so withdrawal stays tolerable; the patient's experience guides the rate.
- If severe withdrawal occurs, return to the last tolerated dose, wait for resolution, then taper more slowly.
Half-life 24–48 hours (active metabolite up to 100 hours). Source: Horowitz & Taylor, The Maudsley Deprescribing Guidelines (2024) — Ch.3 — Suggested direct taper schedules for diazepam (pp. 407–410). These regimens are examples to adapt to the patient, not fixed prescriptions.