Benzodiazepine Equivalencies
Benzodiazepine equivalency tables are used primarily for cross-tapering, switching agents, or managing withdrawal. Unlike opioids, there is no single pharmacodynamic endpoint — clinical context (anxiety, seizure, alcohol withdrawal) significantly affects appropriate dosing.
⚠️ Withdrawal Risk: Abrupt discontinuation of benzodiazepines can cause life-threatening seizures. Always taper slowly. For high-dose or long-duration users, plan a structured taper over weeks to months.
Benzodiazepine Equivalency Table (relative to Diazepam 5 mg)
| Benzodiazepine | Equivalent Dose (mg) | Half-Life (hrs) | Active Metabolites | Onset (PO) | Notes |
|---|---|---|---|---|---|
| Diazepam (Reference) | 5 | 20–100 | Yes (desmethyl-diazepam) | Rapid | Long-acting; preferred for structured tapers |
| Clonazepam | 0.25–0.5 | 18–50 | No | Intermediate | ~10–20x more potent than diazepam; used for seizures and panic disorder |
| Lorazepam | 1 | 10–20 | No | Intermediate | Preferred in hepatic impairment and elderly; IV for status epilepticus. Part of LOT agents. |
| Alprazolam | 0.25–0.5 | 6–27 | Minimal | Rapid | Short-acting; high abuse potential; more difficult to taper |
| Oxazepam | 15 | 4–15 | No | Slow | Safe in liver disease; no active metabolites. Part of LOT agents. |
| Temazepam | 10 | 8–22 | No | Intermediate | Primarily used for insomnia. Part of LOT agents. |
| Chlordiazepoxide | 25 | 5–30 | Yes (desmethyl-diazepam) | Intermediate | Most studied agent for alcohol withdrawal (CIWA protocol) |
| Triazolam | 0.25 | 1.5–5.5 | No | Rapid | Ultra-short acting; significant rebound insomnia; not recommended for long-term use |
| Clorazepate | 7.5 | 40–200 | Yes (desmethyl-diazepam) | Rapid | Prodrug; converted to desmethyl-diazepam in GI tract |
| Midazolam (IV/IM) | ~2.5–5 mg IV | 1.5–3 | Minimal | Very rapid (IV) | Primarily procedural sedation and ICU use; PO formulation used in pediatrics |
| Flurazepam | 15 | 40–250 | Yes | Rapid | Very long-acting; avoid in elderly (Beers Criteria) |
* Equivalent doses are approximate and based on clinical convention, not strict pharmacokinetic equivalence.
* Half-life ranges include parent compound and active metabolites where applicable.
"LOT" Agents — Preferred in Special Populations
| Agent | Why Preferred | Population |
|---|---|---|
| Lorazepam | No active metabolites; direct glucuronidation; unaffected by liver disease | Hepatic impairment, elderly, critically ill |
| Oxazepam | No active metabolites; direct glucuronidation; slow absorption limits misuse potential | Hepatic impairment, elderly, alcohol use disorder |
| Temazepam | No active metabolites; intermediate half-life; minimal accumulation | Hepatic impairment (mild-moderate), insomnia |
Benzodiazepines in Alcohol Withdrawal (CIWA Protocol Context)
| Agent | Typical Regimen | Notes |
|---|---|---|
| Chlordiazepoxide | 25–100 mg q4–6h PRN (CIWA-Ar guided) | Most studied; long half-life provides self-tapering effect |
| Diazepam | 5–10 mg q6h PRN, or symptom-triggered | Self-tapering; preferred for severe withdrawal or seizure prevention |
| Lorazepam | 1–2 mg q4–6h PRN | Preferred in severe hepatic impairment; shorter-acting requires more frequent monitoring |
| Oxazepam | 15–30 mg q6–8h PRN | Safe in mild-moderate liver disease; PO only limits use in severe cases |
Benzodiazepine Tapering Principles
- Convert current benzodiazepine to a long-acting equivalent (diazepam preferred) for structured tapering.
- Reduce total daily dose by no more than 5–10% every 1–2 weeks.
- Taper more slowly as the dose decreases — the final reductions are often the hardest.
- For high-dose or long-duration use, total taper may take months.
- Never abruptly discontinue in physically dependent patients — seizure risk is real and potentially fatal.
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References
Lexicomp Online; IBM Micromedex. Accessed April 2026.
Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed.
Ashton H. Benzodiazepines: How They Work and How to Withdraw (The Ashton Manual). 2002.
Individual US prescribing information for referenced medications via DailyMed. Accessed April 2026.
This resource is intended for educational and reference purposes only and is not a substitute for clinical judgment. Institutional policies, protocols, and locally approved guidelines take precedence. Clinicians should consult their own institution's policies and applicable references before making therapeutic decisions. Version 1.0 — April 2026 — PharmGuides.