feeling awful on cross taper from klonopin to valium.

[[Ko...]]

Hello,

I am in process of crossing over from klonopin 0.5 mg to valium 10 mg at the advice of my NP who supposedly follows the Ashton Manual.  I am currently on 0.25 mg klonopin and 5 mg valium and will move to 0.125 mg klonopin and 7.5 mg valium for a week then drop the klonopin and be on valium 10 mg.  I feel pretty exhausted and depressed but I also felt that way on the 0.5 klonopin. 

I need to work and try and be somewhat functional at home. Presuming I get to the 10 mg of valium, how long should I stay on that dosage and any advice on tapering from there? I will likely need to go slowly as I believe I have tolerance withdrawal symptoms and really need to stay functional so would that be to taper by 5-10% once a month?

Any advice on how to do  this when you get to the lower mg?  I guess you can pill split down to 0.25 mg with the 2 mg tablets but then what. Dry cutting or water tapering? I may have to sort of hide and DIY methods from the NP as she did not look fondly on the DIY methods... But, she did say she would not rush me through the tapering process. 

[[Li...]]

Are you in the US?  If so, are you and your NP aware that a 5mg/5mL (1mg/1mL) oral solution of diazepam is available via prescription? (See link below to the official FDA Drug Label from one of the manufacturers.)  An advantage of using the prescription liquid is that, unlike DIY liquids, it has been proven to be a homogeneous solution; each and every milliliter of the liquid contains exactly the same amount of the Active Pharmaceutical Ingredient (i.e., diazepam). 

A substantial number of our members have used the oral diazepam solution to taper, often in combination with regular tablets.  Here’s an example of how you might taper from 5mg to zero using a combination of tablets and the oral solution:

4mg in tablet form (two 2mg tablets) + 1mg in liquid form, taper liquid to 0 as tolerable
2mg in tablet form (one 2mg tablet) + 2mg in liquid form, taper liquid to 0 as tolerable
2mg in liquid form, taper liquid to 0 as tolerable

DailyMed - DIAZEPAM solution
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9e85abed-1a8b-4762-a31f-f2c7f196b8af

 

[[Ko...]]

I am in the US and aware of the liquid. I am not sure how friendly she will be to prescribing both tablets and liquid at the same time- I will have to see. I guess when the time comes that I get down below 5 mg daily, I will post question about how to dilute the solution to keep to the small percentage cuts vs starting a daily microtaper. 

Thank you for your help!

[[Li...]]

Given that your NP has already indicated she will not rush you through the tapering process, my guess is she will be willing to at least consider this approach.  Based on what I’ve read here, my sense is that, generally speaking, NPs are patient-centered and open-minded regarding such matters.

[[or...]]

Just my thoughts, but in general I think NPs are more compassionate and open-minded than psychiatrists. At least mine was. And I heard the same from other buddies on here during my taper. Mine was truly "on my side" and let me have as much valium as I needed. I saw her weekly and took in my reduction chart so she could see how I was doing. She said "as long as the general direction is down" she'd keep writing scripts. That was incredibly comforting, especially when I had to hold. Hope this helps.  

[[Ko...]]

I hope you two are right. There have been a couple things she said that made me skeptical. I can tell that she thinks I am way too anxious about this process.  First, she wanted to do a straight switch from klonopin to valium and I had to request to do cross-taper (she did agree to that and thankfully I have enough klonopin left as not sure she would have sent that in...)  Secondly, I had mentioned the DIY methods of dry cuts/ water microtapering and she seemed to think that was over the top neurotic and unnecessary with valium.  

I got her practice name from the Benzo information coalition so I may send her the deprescribing guidelines on their website that suggest the 5-10% cuts and discusses microtapering.  Any other ideas?

[[Fa...]]

Hi, @[Ko...],

I normally would not comment and “junk up” someone’s taper thread where @[Li...] was giving her usual unparalleled taper planning and adjustment advice/recommendations; however, you and I have conversed prior, and I have direct personal experience with your current situation.

I would not “send” your NP the attached deprescribing guidance as my experience is that they do not respond as well to this approach.  I would instead suggest bringing it in person with you to your next appointment.  Sincere face to face communication seems to be more efficient from my experience.

Calmly (lacking any anxious and or fast/argumentative speech and tone) bring the document to her attention and kindly ask if she would be willing to prescribe the true solution that Libertas outlined (in addition to the 2mg tablets) so you can safely discontinue your benzodiazepine.  I would again calmly bring to her attention that this was a true solution as Libertas stated, unlike the previous DIY methods you had brought to her attention previously.  

The 3rd, and only other, piece of information you may consider bringing to her attention is the black box warning from Libertas’ attached drug label.  Particularly bullet point number 3.

This worked for me, and I am now tapering with the 2mg tablets and the liquid solution.  My insurance covered both as well (Anthem).  As @[or...] stated, my deprescriber now just basically asks my current dose, acknowleges that I am heading towards 0 (although slower than he thinks necessary) and is relieved I am leaving him alone now. 

3 hours ago, [[L...] said:

DailyMed - DIAZEPAM solution
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9e85abed-1a8b-4762-a31f-f2c7f196b8af

https://corxconsortium.org/wp-content/uploads/Benzo-Deprescribing.pdf

[[Ko...]]

@[Fa...]thank you for your thoughts on this.  I  see her through telehealth visits so not able to bring documents to her face to face.  It will be awhile before I get down to 5 mg anyway so I do have some time to discuss these issues with her.  

May I ask what dosage of valium you started with? And what % cuts you have been making on your way down?

 

[[Fa...]]

@[Ko...] You do not need to wait until you get down to 5mg, nor would I recommend it if you are able to obtain the liquid.  I believe Libertas was just giving you a hypothetical situation. 

15mg cut and hold down to 10mg.  At 10mg I obtained the liquid.  You can see my history in my profile.  I also have a tapering thread you can browse through.  I am going slower than most.  I have to remain functional and I am certain I cannot afford a single additional injury (I’ve encountered a few). 

[[Li...]]

@[Ko...] … @[Fa...] is correct.  I was just giving you a hypothetical.  I strongly encourage you to review  @[Fa...] ‘s history and tapering thread to get an idea of how you might wish to proceed.  He’s doing a grand job of implementing a symptom- and functionality-informed taper.

[[Ko...]]

Many thanks to the both of you.

 

 

[[Ko...]]

Hello,

I am in process of crossing over from klonopin 0.5 mg to valium 10 mg at the advice of my NP who supposedly follows the Ashton Manual.  I am on the 10th day of valium and currently on 5 mg of valium and .25 mg of klonopin. Since I started the cross taper I have been feeling progressively worse- I am not sure what is medication side effect and what is withdrawal from klonopin. I have extreme fatigue, depression and anhedonia with skin burning, exercise intolerance, muscle pain and weakness. I am supposed to take next step in switch to valium with another increase in that to 7.5 mg and decrease in klonopin to .125mg. I feel so stuck. I see the nurse practitioner next week. Any advice or feedback?

[[Fa...]]

@[Ko...] I would recommend slowing down your transition from clonazepam to diazepam.  Also, you are doing nothing wrong, however, I would recommend keeping all your questions/concerns regarding your taper all on one thread so members can best assist you. 

[[Ko...]]

I just started a new thread on the trouble I am having making the switchover from klonopin to valium...

[[Ko...]]

That makes sense. I don't know how much more I can slow down as I don't think this NP will call me in anymore klonopin. So I only have enough for another 4 days of 0.5 klonopin and then 7 days of .125 of klonopin. 

I think I mentioned before that I can't tell what is sedation from starting valium vs fatigue from withdrawal.

[[de...]]

You might gently explain to your NP that it is advisable to make a reduction, or not, based on what your body is telling you.   If you are able to slow your transition down, that would be preferable, at least until you stabilize for a bit.  

Also, it would be a great idea to keep all your questions, thoughts, concerns on one thread so we can all stay on the same page, so to speak.   This makes for a much more effective way to get consistent, meaningful feedback.

 

[[Pa...]]

Hello @[Ko...], two things we need from you in order to make the best suggestions.

Please fill in your medication history, this allows anyone to see at a glance what has been happening rather than going back through all of your posts, this helps us help you.  Here are the instructions. 

 

And secondly, please confine your taper questions to a single thread, this allows you to have all of the information in one location, making it easier for you and the members contributing to your thread see the great suggestions you’ve already been given. I’ve merged your two taper threads. 

 

[[Ko...]]

I filled in my history on my profile. I am meeting with my NP today to review my crossover. Still feeling pretty crappy.

[[Ko...]]

Hi again- I started on 0.5 mg of clonazepam and am in the middle of a cross taper- filled in my history on my profile.

I have been on 0.25 mg clonazepam and 5 mg valium for past 2 weeks. I started with the valium crossover 3 weeks ago.  I feel so fatigued, depressed, and unmotivated with brain fog. I also have some nausea, episodic mild dizziness,  and malaise.  All I feel like doing is lying around- this is really not an option as I need to be working.

I can't tell if I am having withdrawal from clonazepam or am overmedicated now that the valium has taken full effect at 3 weeks.  Is there anyway of telling? I have some mild tinnitus but not anxious or agitated.  Previous withdrawal symptoms from attempting to lower the klonopin too abruptly were severe tinnitus and electric surging like I was filled with electricity so I think that I am overmedicated.

The NP wants me to go to 10 mg of valium and get rid of clonazepam. Or should I just go to 7.5 mg of valium since I feel so overmedicated?  I know Ashton equivalent was 0.5 clonazepam to 10 mg of diazepam but I am wondering if I fall on the  lower end of things

Or I could go to 7.5 mg of valium and do a week of .125 mg clonazepam for a week and then transition over to the 10 mg of valium.

I did discuss with her all of these issues and she is firm on wanting me to switch to all valium and dropping the klonopin- I wish there was a way of knowing what to do....I only have the 5 mg valium tablets to work with. She definitely thinks I am overly anxious and OCD- wants me to start gabapentin and prozac but I am not doing those things.

[[Pa...]]

Has the sedation improved at all?  Many members have said it will dissipate as you acclimate to it.  Professor Ashtons equivalencies were higher than other suggested doses so it makes sense to find what works for you.

I support you in your desire to avoid more medication right now, it’s tough to get a proper diagnosis when we’re going through this, many of our members get labels which have nothing to do with us, we’re simply reacting to the drug withdrawal and adding more medications mean more side effect and more tapers. But of course, if you and your doctor both agree they could be useful then that’s the best course of action.

 

[[Ko...]]

I continue to be extremely fatigued in the mornings no matter how much sleep I am getting.  I don't really feel sedated all day long- more fuzzy and out of it.  I decided to do .125 mg of klonopin with 7.5 mg valium for a week before going to only valium. I suppose I will go to the 10 mg dosage of valium and then start the reduction from there by going to 9.5 mg and seeing how that goes.

I will need help with taper plan after that.  My prescriber is willing to go slowly (5% per month or whatever tolerated) and use the liquid diazepam but does not agree with microtapering and DIY methods (scales, water titration).  I am interested in the microtapering anyway as it seems a lot of people are better able to remain highly functional using that strategy. 

 

[[Fa...]]

@[Ko...] I too feel extremely fatigued in the mornings no matter how much sleep I get.  I like your plan to keep another stage with the clonazepam before switching to 10mg diazepam.  My suggestion is to then hold for one month.  

That is such great news your NP is willing to prescribe the liquid solution!  I would then follow @[Li...] hypothetical outline per below quote, except I would start at 8mg tablets and 2mg/ml liquid and taper liquid to 0 as tolerable.  If you have not had time to review my taper thread, I would highly encourage it.  It will most likely answer some additional questions you may have regarding how you wish to proceed.  I've attached a link. 

On 24/08/2023 at 17:35, [[L...] said:

A substantial number of our members have used the oral diazepam solution to taper, often in combination with regular tablets.  Here’s an example of how you might taper from 5mg to zero using a combination of tablets and the oral solution:

4mg in tablet form (two 2mg tablets) + 1mg in liquid form, taper liquid to 0 as tolerable
2mg in tablet form (one 2mg tablet) + 2mg in liquid form, taper liquid to 0 as tolerable
2mg in liquid form, taper liquid to 0 as tolerable

DailyMed - DIAZEPAM solution
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9e85abed-1a8b-4762-a31f-f2c7f196b8af

[[Ko...]]

Thanks for checking in @[Fa...].

I am almost tempted to cross over to less than 10 mg of the diazepam but that would probably be a bad idea....

I don 't think my NP will let me start making the reductions with the liquid quite yet. She seems pretty rigid. So I will need to start with the 5% reduction from 10 to 9.5.  If I tolerate that pretty well, I may try to go to 9 before making the switch to liquid.

Are you doing hyperbolic taper or linear? I am hoping for 5-10 % reduction every 3-4 weeks but would like that to be conducted as a daily reduction once I get the liquid. That's when I will need a lot of help with the math as I will have to tell her I am doing the decrease. as a cut and hold rather than a daily reduction...(hopefully that makes sense...)

[[Fa...]]

Hi, @[Ko...].  I agree - at this point, I would continue to cross to 10mg diazepam.  I think it is worth a discussion with your NP regarding reductions via liquid sooner rather than later.  She seems to be working with you.  If she is willing to prescribe the liquid diazepam, and that is the direction you all are heading, why not allow you to start reducing via the liquid at 10mg vs. 9mg?  Either way, it will be fine.

Did you have a chance to read through the taper thread I attached?  It should answer some of your questions.  In essence, I am tapering at my own pace.  We are all different.  I am adjusting as I go, letting my body tell me what it can handle.  Honestly, for me it seems to vary and there are changing variables in my life and taper as well (ie. work stress, travel, dosage form change - dropping tablets and adding higher percentage of liquid).  I am keeping what we know re: Horowitz-Taylor hyperbolic research, and what we know about relatively associated recommended exponential taper strategies in mind.  The most I have tapered so far since switching to liquid was 4.8% over a month stretch.  It happened to be my best monthly stretch in regards to symptom severity as well.  Go figure...  

When actively tapering, I am currently reducing by roughly .2mg/ml every 2 weeks via daily reductions of .02mg/ml and .01mg/ml.  I am approaching 8mg and have 2 trips scheduled in October.  I will most likely be holding the month of October at 8mg tablet form before dropping another 2mg tablet for liquid, as I don't want to risk an uptick in discomfort and symptoms during this period of time.  My goal is to actively taper around .2mg/ml every 2 weeks for now and hold at .5mg/ml intervals.  As a result, I plan to see if I can push up my exponential taper rate after my hold at 8mg.  This all can obviously change.

[[Pa...]]

7 hours ago, [[K...] said:

If I tolerate that pretty well, I may try to go to 9 before making the switch to liquid.

I wanted to share something members have mentioned when they make the cross to liquid, @[Fa...] may have already mentioned it but holding while you make the transition can be helpful.  It may be because of the different formulation, or the slight difference in dose when switching but I wanted to pass this along.