Question 1

What is the equivalent of alprazolam 1 mg in diazepam?

Accepted Answer

Alprazolam 1 mg is approximately equivalent to **diazepam 20 mg**. The standard anchor is alprazolam 0.5 mg ≈ diazepam 10 mg ≈ lorazepam 1 mg ≈ clonazepam 0.5 mg, though individual sources vary by 20–30%.

Question 2

How do I taper a patient off lorazepam?

Accepted Answer

Convert to a diazepam-equivalent total daily dose, then reduce by approximately 10% of the current dose every 1–2 weeks. Below 5 mg/day diazepam-equivalent, slow the reduction further (0.5–1 mg every 2 weeks). Tapering directly from lorazepam without converting to a long-acting agent is feasible but produces sharper inter-dose withdrawal symptoms.

Question 3

Why do you taper with diazepam instead of the original benzodiazepine?

Accepted Answer

Diazepam has a very long half-life (20–100 hours, with active metabolites). This smooths the inter-dose troughs that drive withdrawal symptoms and relapse, particularly when the patient was on a short-acting agent (alprazolam, lorazepam) where each dose's wearing-off triggers a craving cycle.

Question 4

Is alprazolam stronger than lorazepam?

Accepted Answer

Per mg, yes — alprazolam 0.5 mg ≈ lorazepam 1 mg. Alprazolam is also harder to taper than lorazepam because of its shorter half-life and steeper inter-dose decline, which makes its dependence profile arguably the worst among commonly prescribed benzodiazepines.

Question 5

Which benzodiazepine is safest in liver disease?

Accepted Answer

Lorazepam and oxazepam undergo glucuronide conjugation rather than oxidative metabolism, so they have no active metabolites and don't accumulate in cirrhosis or in elderly patients. Diazepam, chlordiazepoxide, and midazolam should be avoided or used with caution in advanced liver disease.

Question 6

How fast can I taper benzodiazepines safely?

Accepted Answer

The Ashton manual and most modern references recommend ~10% of current dose every 1–2 weeks, with a slower pace below 5 mg diazepam-equivalent. Tapers of 6 months to 18 months are common for long-term users. Rapid inpatient tapers risk rebound anxiety, insomnia, and (with very abrupt cessation at high doses) seizures.

Drug	Daily dose	Half-life
Diazepamlong	40mg	20–100 hr (with active metabolites)
Lorazepamintermediate	4mg	10–20 hr
Alprazolamintermediate	2mg	6–12 hr
Clonazepamlong	2mg	18–50 hr
Midazolamshort	27mg	1–4 hr
Temazepamintermediate	80mg	8–22 hr
Oxazepamintermediate	120mg	4–15 hr
Chlordiazepoxidelong	100mg	5–30 hr (with active metabolites)
Triazolamshort	0.8mg	1.5–5 hr
Flurazepamlong	60mg	40–250 hr (with active metabolites)

Benzodiazepine Equivalence

References

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