Deprescribing Benzodiazepines and Proton Pump Inhibitors: Tapers That Work and How to Monitor

Benzodiazepine receptor agonists (benzodiazepines and the Z-drugs) and proton pump inhibitors are the two drug classes most often deprescribed in older adults, and the deprescribing.org guidelines give each a clear pathway. For a benzodiazepine or Z-drug taken for insomnia by an adult 65 or older, recommend a slow taper regardless of how long it has been used: about 25 percent of the dose every 2 weeks, 12.5 percent steps or planned drug-free days near the end, CBT-I alongside, and contact every 1 to 2 weeks. For a PPI whose indication has run its course, lower the dose or stop it and use it on demand, then check for returning symptoms at 4 and 12 weeks.

Why these two classes

The 2023 Beers Criteria list all benzodiazepines and the nonbenzodiazepine hypnotics (zolpidem, eszopiclone, zaleplon) to avoid in older adults because of cognitive impairment, delirium, falls, fractures and motor vehicle crashes, with little lasting gain in sleep. The deprescribing.org guideline adds physical dependence, memory disorder, functional impairment and daytime sedation, and notes that sleep benefits wane after about 4 weeks while the harms continue and grow with age.

PPIs are on the Beers list to avoid beyond 8 weeks unless the patient is high risk (oral corticosteroids or chronic NSAID use), has erosive esophagitis, Barrett esophagus or a hypersecretory condition, or has shown a need for maintenance. The PPI algorithm lists the associated harms as fractures, C. difficile infection and diarrhea, community-acquired pneumonia, vitamin B12 deficiency and hypomagnesemia. Many older adults remain on a PPI started for a short-term indication, such as hospital stress-ulcer prophylaxis, that no one revisited.

Part 1: benzodiazepine receptor agonists

Who the guideline covers

The 2018 guideline applies to adults taking a BZRA for insomnia on its own, or for insomnia whose underlying comorbidities are managed.

If the indication is unclear, find out whether there is a history of anxiety, a past psychiatric consultation, or whether the drug was started in hospital for sleep or during a grief reaction.

Engaging the patient

Explain the reason (the risks of continued use and the loss of effect over time), what withdrawal feels like and that it is usually mild and short, and that the patient controls the pace. The algorithm lists the expected benefits of stopping: better alertness and cognition, less daytime sedation and fewer falls.

The taper

The algorithm suggests reducing by about 25 percent every 2 weeks and, if possible, using 12.5 percent reductions near the end or planned drug-free days. Reductions are calculated from the starting dose, so the steps stay equal.

Practical rules from the algorithm:

• If available strengths do not allow 25 percent steps, start with a 50 percent reduction and use drug-free days in the later part of the taper, or switch to lorazepam or oxazepam for the final steps.
• Switching to a long-acting agent such as diazepam is not supported by evidence as a way to reduce withdrawal.
• If symptoms relapse, hold the current dose for 1 to 2 weeks, then continue at a slower rate.

The 2025 Joint Clinical Practice Guideline on Benzodiazepine Tapering, led by the American Society of Addiction Medicine, addresses long-term users and those with physical dependence more broadly. It calls for an individualized taper, commonly starting with reductions of 5 to 10 percent every 2 to 4 weeks and generally not exceeding 25 percent every 2 weeks, slowed further when withdrawal is significant, and it warns that some tapers take months or longer. For an older adult on a long-standing, higher dose, the slower schedule is the safer default.

Monitoring

For patients 65 and older, monitor every 1 to 2 weeks for the duration of the taper. Withdrawal symptoms are insomnia, anxiety, irritability, sweating and gastrointestinal upset, usually mild and lasting days to a few weeks. Ask about sleep with a sleep diary, daytime function, falls, mood and any substitution with alcohol or over-the-counter sedating antihistamines such as diphenhydramine, which the Beers Criteria also list to avoid.

Treating the insomnia without the drug

CBT-I is the treatment that replaces the hypnotic. It usually involves 5 to 6 sessions covering sleep education, stimulus control, sleep restriction, sleep hygiene and relaxation, and it produces sustained benefits; combined with tapering, it improves the chance of stopping. Psychologists usually deliver it, but trained clinicians and self-help programs can provide parts of it. Behavioral advice for primary care:

• Go to bed only when sleepy, and use the bed only for sleep or intimacy.
• If not asleep within about 20 to 30 minutes, leave the bedroom and return when sleepy.
• Get up at the same time every morning, and do not nap.
• Avoid caffeine after noon, and avoid exercise, nicotine, alcohol and large meals within 2 hours of bedtime.

In long-term care, the algorithm adds daytime light exposure, more daytime activity, short naps only before 2 pm, toileting before bed, minimal alarm noise and avoiding waking residents for care at night.

Referral triggers

Consult psychiatry, addiction medicine or a sleep specialist when the patient has a substance use disorder, concurrent opioid use, a history of withdrawal seizures or delirium, a benzodiazepine prescribed for a psychiatric disorder, suspected sleep apnea or restless legs, or repeated failed tapers.

Part 2: proton pump inhibitors

Start with the indication

The algorithm sorts patients by why they take the PPI.

Two equal options

Lower the dose, for example from twice daily to once daily, halving the dose, or taking it every second day; the evidence suggests no increased risk of symptom return compared with continuing the higher dose. Or stop and use the PPI on demand: take it daily until symptoms resolve, then stop until they recur; about 1 in 10 patients may have symptoms return. The algorithm treats these as equally recommended, strong options and states that no tapering approach has been shown better than another, so choose what is most convenient and acceptable to the patient.

Standard and low daily doses from the algorithm:

Monitoring

Review at 4 and 12 weeks. In patients who can describe symptoms, ask about heartburn, regurgitation, dyspepsia and epigastric pain; in patients who cannot (advanced dementia), watch for loss of appetite, agitation and weight loss.

If symptoms return:

• Non-drug measures: avoid meals 2 to 3 hours before bedtime, elevate the head of the bed, lose weight if needed and avoid dietary triggers.
• Occasional symptoms: over-the-counter antacid, alginate, H2 receptor antagonist or PPI as needed; a daily H2 receptor antagonist is a weak-recommendation option.
• Symptoms persisting 3 to 7 days and interfering with normal activity: test and treat for H. pylori and consider returning to the previous dose.

Alarm features such as GI bleeding, anemia, dysphagia, persistent vomiting or unintended weight loss are not rebound; they need prompt evaluation and gastroenterology referral.

How the exam tests this

• The abrupt stop. An option discontinues a long-term benzodiazepine today; the correct answer tapers it. The exception is a few days of use.
• The swap. Replacing a benzodiazepine with zolpidem, or diphenhydramine for sleep, swaps one Beers drug for another. The answer pairs the taper with CBT-I.
• The diazepam conversion. Switching to a long-acting agent is not required and does not reduce withdrawal; it is a distractor unless the stem gives a specific reason.
• The age trap. For 65 and older, deprescribing is recommended regardless of duration; for younger adults, after more than 4 weeks.
• The taper rate. About 25 percent every 2 weeks, slower near the end; follow-up every 1 to 2 weeks. An option halving the dose weekly is too fast for a long-term user.
• The PPI indication. Barrett esophagus, severe esophagitis, a bleeding ulcer history or chronic NSAID use with bleeding risk means continue; healed mild esophagitis or controlled GERD after 4 to 8 weeks means deprescribe.
• The PPI follow-up. Symptom review at 4 and 12 weeks, with H. pylori testing if symptoms persist and interfere with activity.

Practice question

A 78-year-old man presents for a medication review with his wife. He has taken temazepam 30 mg nightly for 9 years, started during a hospital stay, and omeprazole 20 mg daily for 4 years, started for heartburn that resolved within the first months; he has never had endoscopy, GI bleeding or regular NSAID use. He has no anxiety disorder, depression screen is negative, and his wife reports no snoring or witnessed apneas. He had one fall last winter and describes morning grogginess. He is interested in reducing his medications. Which of the following is the most appropriate plan?

• A. Stop temazepam and omeprazole today, and start trazodone 50 mg at bedtime for sleep.
• B. Convert temazepam to an equivalent dose of diazepam, then taper the diazepam over 2 weeks; continue omeprazole.
• C. Taper temazepam by about 25 percent of the dose every 2 weeks with CBT-I and follow-up every 1 to 2 weeks, and reduce omeprazole to 10 mg daily or switch to on-demand use with symptom review at 4 and 12 weeks.
• D. Continue both medications, because long-term use without problems shows they are well tolerated.

Answer: C. He is over 65 and takes a BZRA for insomnia, so the guideline strongly recommends a slow, collaborative taper with behavioral therapy and close follow-up, and his fall and morning grogginess are the harms the taper addresses. His PPI was started for symptoms that resolved, with no Barrett esophagus, severe esophagitis, bleeding history or NSAID risk, so lowering the dose or using it on demand is appropriate, with review at 4 and 12 weeks. Option A stops a 9-year benzodiazepine abruptly, risking significant withdrawal, and substitutes a sedating drug without addressing the insomnia behaviorally. Option B uses a conversion that is not shown to reduce withdrawal and a 2-week taper that is far too fast, and it keeps a PPI without an indication. Option D ignores a fall and daytime sedation in a patient on two drugs listed in the Beers Criteria.

Key points

Related NPPace guides

• Falls Assessment in Older Adults: STEADI, Gait Tests, Medications and the Home
• Polypharmacy Review in 10 Minutes: A Provider's Method for the Visit and the Exam
• Beers Criteria on the NP Exam: The Drugs to Avoid in Older Adults and What to Use Instead
• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
• AANP vs ANCC: Which NP Certification Exam Should You Take?