# A nurse is caring for a patient who has been taking lorazepam (Ativan) 2 mg twice daily for anxiety for the past 6 months. The patient reports wanting to discontinue the medication. What is the most important nursing action?

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## 문제

A nurse is caring for a patient who has been taking lorazepam (Ativan) 2 mg twice daily for anxiety for the past 6 months. The patient reports wanting to discontinue the medication. What is the most important nursing action?

## 보기

1. Advise the patient to stop taking the medication immediately to avoid dependency
2. Recommend switching to an over-the-counter sleep aid as a substitute
3. Suggest the patient reduce the dose by half every few days until discontinued
4. Collaborate with the healthcare provider to develop a gradual tapering schedule **✔ 정답**

**정답: 4**

## 해설

Benzodiazepines like lorazepam require gradual tapering under medical supervision to prevent dangerous withdrawal symptoms such as seizures. Other options risk abrupt withdrawal or inappropriate substitution.

## 심화 해설

Understanding the Clinical Scenario

The patient has been on a consistent dose of lorazepam (Ativan), a benzodiazepine receptor agonist (BZRA), for 6 months. This duration of use is significant because it extends well beyond the short-term treatment window, establishing a high probability of physical dependence. The patient's desire to stop the medication is a critical moment where nursing intervention must prioritize safety by preventing a potentially severe withdrawal syndrome.

Why Immediate Discontinuation or Self-Tapering is Dangerous

Advising the patient to stop immediately (Option 1) or to reduce the dose by half every few days (Option 3) contradicts the pharmacological principles of safe BZRA deprescribing. Abrupt cessation or rapid, linear reductions are high-risk strategies. After 6 months of use, the patient’s neurophysiology has adapted to the presence of the drug. A sudden drop in dosage can trigger a severe and protracted withdrawal syndrome [4]. Symptoms are not merely a return of anxiety but can include life-threatening complications such as seizures, psychosis, and severe autonomic instability. A meta-analysis of deprescribing interventions confirms that structured, gradual strategies are necessary to mitigate these harms, and that simply advising a patient to reduce without a tailored plan is often unsuccessful and unsafe [1].

The Pharmacological Basis for Gradual, Hyperbolic Tapering

The most current evidence-based guidance moves away from linear dose reductions (e.g., cutting by 1 mg at a time) and instead recommends a gradual, proportionate (hyperbolic) tapering schedule [4]. This means reducing the dose by a percentage of the most recent dose (e.g., 5-10% every 1-4 weeks), not the original dose. This approach accounts for the hyperbolic relationship between BZRA receptor occupancy and drug dose, meaning that at lower doses, even small absolute reductions can lead to a massive drop in receptor occupancy, triggering intense withdrawal. A modified Delphi consensus from a multi-disciplinary expert panel explicitly recommends this individualized, flexible approach to minimize withdrawal symptoms and optimize deprescribing success, highlighting that standard, rigid protocols often fail .

The Nurse's Role in Collaborative Management

The most important nursing action is to collaborate with the healthcare provider (Option 4). As a nurse, you are not authorized to prescribe a tapering schedule, but you are responsible for recognizing the risk, advocating for the patient, and facilitating a safe plan. A systematic review focused on older adults confirms that structured deprescribing strategies, which are inherently collaborative and multidisciplinary, are the standard of care to safely reduce chronic BZRA use . Recommending an over-the-counter substitute (Option 2) is inappropriate and potentially dangerous, as it does not address the underlying BZRA dependence and could lead to additive sedation or other adverse effects. The nurse’s role is to educate the patient on why a gradual, provider-supervised taper is medically necessary, to monitor for withdrawal symptoms using a validated tool, and to provide non-pharmacological support throughout the process. The evidence is clear that a successful deprescribing plan is one that is individualized, gradual, and managed by a healthcare team, not a self-directed or abrupt cessation attempt [2,4].References (research sources)

- [1]Comparative effectiveness of interventions to facilitate deprescription of benzodiazepines and other sedative hypnotics: systematic review and meta-analysis.Meta-analysis/systematic reviewZeraatkar D, Nagraj SK, Ling M, Jassal T, Kirsh S, Lima JP, Pitre T, Couban R, Hussain M, Seterelv S, Van de Velde S, Gustavsson K, Wichniak A, Aubert CE, Christiaens A, Spinewine A, Agoritsas T. (2025) · DOI: 10.1136/bmj-2024-081336

- [4]Pharmacological principles for safe benzodiazepine and Z-drug dose reduction.Research articleHorowitz M, Lamberson N, Brandt J, Framer A, Shapiro B, Sørensen A, Cadogan C, Ritvo A, Taylor D. (2026) · DOI: 10.1017/s0033291726104887

## 임상 시나리오

Benzodiazepine Deprescribing: Clinical GuidePrioritizing Safety in Long-Term Lorazepam Use
For a patient on lorazepam 2 mg twice daily for 6 months, the priority is a provider-directed gradual taper. Abrupt or rapid self-discontinuation risks a severe withdrawal syndrome including seizures and psychosis.

The most current evidence supports hyperbolic tapering, where doses are reduced by progressively smaller amounts proportional to the current dose. This accounts for the drug's receptor occupancy curve, minimizing neuroexcitation and withdrawal symptoms compared to linear reductions.

CautionNever advise a patient to abruptly stop or independently halve their benzodiazepine dose. These actions can precipitate life-threatening autonomic instability. Always collaborate with the prescriber to establish a safe, individualized tapering plan.

## 핵심 개념

- **Benzodiazepine Withdrawal Syndrome** — A potentially life-threatening condition resulting from abrupt discontinuation of a benzodiazepine, characterized by anxiety, insomnia, seizures, psychosis, and autonomic instability.
- **Hyperbolic Tapering** — An evidence-based deprescribing strategy where the dose is reduced by smaller and smaller amounts proportional to the current dose, based on receptor occupancy, to minimize withdrawal symptoms.
- **Physical Dependence** — A physiological state of neuroadaptation to a drug, where abrupt cessation leads to a withdrawal syndrome, distinct from addiction.
- **Lorazepam (Ativan)** — A short-to-intermediate-acting benzodiazepine used for anxiety, carrying a high risk of physical dependence with regular use beyond 2-4 weeks.
- **Deprescribing** — The planned and supervised process of dose reduction or stopping of a medication that may be causing harm or is no longer providing benefit.

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