The Waco Guide

Yes
No
Present
Absent
Pt does not meet criteria for
specific psychiatric disorder
Deprescribing Indicated
Able to complete taperUnable to complete taper
Benzodiazepine Deprescribing
Interview patient regarding
history of benzodiazepine use,
other prescriptions, and substance
use history
Benzodiazepine used to treat
comorbid psychiatric disorder?
See corresponding
decision support and reevaluate
need for benzodiazepine
Patient/family
education
Discuss risks of benzodiazepine use,
possible loss of benzodiazepine efficacy,
and potential of withdrawal symptoms Educate patient and family about process of gradual taper
rather than abrupt discontinuation
Establish goals for deprescribing
Slow taper over weeks to months
(max of three months) using a
scheduled dosing regimen
Follow up and monitor after each dose reduction
Monitor for emerging symptoms of withdrawal
(insomnia, restlessness
irritability, anxiety
gastrointestinal symptoms
diaphoresis)
Maintain benzodiazepine dose for
additional 1-2 weeks then resume taper
Continue taper
continue follow up and monitoring
See corresponding Decision Support
If applicable
(e.g. for emerging anxiety or insomnia)
Consider Adjunctive Agents
for Withdrawal:
Buspirone
Clonidine
Gabapentin
Hydroxyzine
Deprescribing strategies:
Decrease dose by 20% every 2 weeks
-or-
Decrease dose by 25% every 2 weeks;
hold at 50% of dose for one month; then
decrease by 5-10% weekly to monthly
Consider restarting more
gradual taper
or
Maintain patient on
minimum effective
benzodiazepine dose
Maintain benzodiazepine- free status
Encourage appropriate coping and
relapse-prevention skills
Discuss especially high risk of adverse events
including seizures and hospitalization
from abrupt discontinuation with
Alprazolam or Clonazepam > 4 mg total

Is a comorbid disorder present?

Is the patient currently undergoing taper?