Pharmacist tapering off clonazepam would like advice please ! I am new .

[[so...]]

Hey guys , heard about this forum , wanted to get your advice . As yoh read I am a pharmacist , been on 3 mg clonazepam for roughly 15+ years . Took it for generalized anxiety disorder when I was a kid . Prob shoulda not done that ! 
 

I started tapering 0.25 mg monthly off my daily dose in June of 2023 . I recently hit 1 mg daily and these withdrawals started hurting man . Nausea (which I hate ) , low appetite , minor anxiety attacks , sweating .. you all prob know . Been one month now on 0.5 mg AM and 0.5 mg PM . I use 100mg gabapentin Once to 3 times daily for calming . Valerian tea to help sleep . I have to remain highly functional and do not think I can continue dropping 0.25 mg daily / per month … it’s hurting mentally . I didn’t have anxiety like this when I began taking it , so I attribute it to withdrawel . anyone have any advice regarding other drugs to help smoothe the withdrawal ? I hear lyrica is showing good off label use to curb anxiety and other symptoms . I was considering dropping (when I feel better ) by 0.125 mg which is as low as I can get in a pharmacy . any advice is appreciated . Thanks guys . 
 

 

[[Al...]]

Hi @[so...] 

I understand the urge to take something to smooth withdrawal, but I would be careful with Lyrica (Pregabalin). You could easily get dependent and need to taper off that as well. I think the best strategy would be to take the time to stabilize and then start a slower taper. Hopefully some of the more experienced members of the site can add their insight here and hopefully suggest a suitable taper rate for you.

Edited April 27 by [Al...]

[[so...]]

Ty much . Yeah I’m hesitant to start pregabalin . I have many patients hooked to the gills on it . I’ll steer clear . I was going to ask the doc to give me a bunch of 0.125 odt clonazepam tabs to combine with the halved 0.5 so I can come down slower . That’s the best I can do using retail pharmacy obtainable products . Maybe a compound pharmacy could help ? Be well . 

[[Li...]]

1 hour ago, [[s...] said:

I was going to ask the doc to give me a bunch of 0.125 odt clonazepam tabs to combine with the halved 0.5 so I can come down slower . That’s the best I can do using retail pharmacy obtainable products . Maybe a compound pharmacy could help ?

Hello @[so...].  Given your benzodiazepine use history and response to the last reduction from 1.25mg to 1mg, you may need to decrease your taper rate — perhaps below what is achievable using the 0.125mg ODTs.  (Fyi … generally speaking, smaller more frequent reductions are better tolerated than larger less frequent ones, especially when tapering a potent benzodiazepine like clonazepam.)

If this proves to be the case, many members have used a compounded liquid to taper successfully.  Several formulations are available including this one for a 0.1mg/mL oral clonazepam suspension made with regular tablets as the source of the active ingredient.  (Some compounding pharmacists also have access to formulations that use bulk powder as the drug source and yield a solution instead of a suspension.)

Given that you are a pharmacist and therefore in a position to educate both yourself and your patients about how to safely discontinue benzodiazepines, might I encourage you to obtain a copy of The Maudsley Deprescribing Guidelines (Horowtiz & Taylor, 2024)?  In it, you will learn about the importance of adjusting taper rate in response to withdrawal symptoms as well as the steps in the tapering process (including estimation of the risk of withdrawal) and examples of faster, moderate, and slower tapering regimens for clonazepam (as well as for other benzodiazepines and z-drugs). 

[[so...]]

Ty very much , I will look up those references and read next chance I get . I dunno if my md would be able to understand the liquid taper . How much smaller would you go ? If 0.125 is not great , maybe cut those in half ? And what drugs do you recommend as anxiety relief during withdrawal ? I hear lyrica is showing great results , but is also quite addictive . Thanks much for the support . 
 

I just noticed you included a formula for a nice suspension . I can easily make that . Cool . Ty . Another question . I am currently at 0.5 am and 0.5 pm , when I’m ready to drop , would you take away evenly alternating morning and bedtime ? Or get rid of morning dose and then focus on night time ? Ty much . 

Edited April 27 by [so...]
Found a formula

[[Ma...]]

Welcome to the forum.  Physician here also tapering Clonazepam.  I was on 1mg when I started tapering in July 2023 and at .3 now.   The receptor binding curves unfortunately are such that it does tend to get a little harder below 1mg.  Recommendations are generally 5-10% every 10-14 days but you may be able to go faster (or have to go slower) depending on how your symptoms go.  
   I’m also on Gabapentin after an accident and sustained neuropathic injury, taking 600mg at night.  I will be on this for life and I’m ok with that.  I’ve been on this dose for over a decade with no issues and I have heard that it coincidentally for me anyways, helps with BZP WD.  While some people claim coming off it is as hard or harder, anecdotally this doesn’t seem to be the case for the majority of people.  I would avoid Lyrica because it does seem to have more abuse potential.  

Edited April 27 by [Ma...]

[[Li...]]

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

I am currently at 0.5 am and 0.5 pm , when I’m ready to drop , would you take away evenly alternating morning and bedtime ? Or get rid of morning dose and then focus on night time ?

Our nervous systems prefer consistency.  Consequently, unless you have a compelling reason to change your dosing schedule, I suggest continuing to dose two times a day and either splitting the target reduction evenly across the two doses or alternating reductions between the two doses.

[[so...]]

Ty , I agree with both . Avoid lyrica and go slower . I’m taking 100mg gabapentin 2-3 times daily . should I stop this ? Will this cause crazy withdrawel ? How nasty  is weaning off gaba ? Ty . 

[[Li...]]

8 hours ago, [[s...] said:

I’m taking 100mg gabapentin 2-3 times daily . should I stop this ? Will this cause crazy withdrawel ? How nasty  is weaning off gaba ?

Generally speaking, it’s preferable to taper one medication at a time so you can get a clear read on your response to reductions.

How long have you been taking the gabapentin?

Is it having the desired therapeutic effect? Or, is it causing you issues (e.g. adverse reactions)?

The only way to know how you will respond to tapering gabapentin is via self-experimentation.  Some individuals can taper it without major issues whereas others have difficulty.  

 

[[so...]]

Ehh , I was taking 100mg at bedtime regularly for 2-3 months . Last few weeks I’ve been increasing to twice daily 100 mg …. Nothing crazy … maybe I’ll just go back to 100 mg at night for sleep . I don’t want another monkey on my back . 

[[Ma...]]

If it’s not helping you, you can probably just stop it; that’s a small dose you’re on and the half life is short (5 hours).  The people who most often get into trouble with Gabapentin, unlike with benzos, are the ones taking large doses, usually 1800/day or more.  

[[Li...]]

 

Hello @[so...].

If you decide to reduce or discontinue the gabapentin …

Given that your nervous system is in a sensitized state due to your 20% reduction in dose from 1.25mg to 1mg clonazepam  …

In your shoes, I would err on the side of caution and (1) hold the clonazepam taper at 1mg and (2) implement a ‘as fast as tolerable’ response-guided taper of the gabapentin.  

In the US, gabapentin is available as a 250mg/5mL oral solution, so you could reduce it in steps of 25mg or lower if needed.  Gabapentin has a half-life of 5 to 7 hours so you should be able to get a quick read as to whether or not you tolerate whatever taper rate you choose.  If not, you could slow the rate down.

After you complete the gabapentin taper, you could return to your clonazepam taper (assuming your symptoms have stabilized and you feel ready to proceed).  Speaking of which, have you had the opportunity to check out The Maudsley Deprescribing Guidelines (MDG)?  I think you’ll find it both interesting and helpful.    

For example, your taper to date has been somewhere between the ‘faster’ and ‘moderate’ clonazepam taper schedules in MDG.  You may need to move to a ‘moderate’ or even ‘slower’ schedule for the remainder of your taper.  It all depends on how you respond to reductions moving forward.  In your shoes, I’d probably try a 5 or 10% reduction in dose for the next step (e.g. from 1mg to 0.95mg or 0.9mg total daily dose).  It’s far easier to speed up a too slow taper than it is to slow down and recover from a too fast taper.

 

[[so...]]

Ty guys , the plan at this point is to stay at 1 mg daily until symptoms resolve . Mostly I’m dealing with anxiety and nausea (mild) , sweating .. etc . After I’m feeling confident to move forward , I will try 0.125mg odt , which is about 12.5% decrease . I will probably take 100 mg of gabapentin nightly , for sleep help . if this becomes intolerable , I will compound the ora sweet formulation you sent me   , and go even slower . I have a bunch of 2 mg tabs around and access to the equipment needed . I haven’t had a chance to look at the deprescribing guidelines yet , but I wil . Promise . Ty guys for getting back to me .. this is gonna be a wild ride . 

[[Li...]]

Thank you for letting us know your next steps @[so...].  I hope you’ll continue to keep us posted so we all can learn from your experience.

I’m glad you’re going to hold at 1mg until your symptoms stabilize (i.e. stop changing in number and nature).  If you’re not already doing so, I encourage you to keep a daily taper journal.  It can be as simple as the date, your dosing times and amounts, and two global ratings — one for your symptoms and one for your functionality level (e.g. 0 = no withdrawal symptoms, able to complete all essential daily tasks; 10 = intolerable symptoms, unable to complete any essential daily tasks).  Review the data in your journal on a regular basis to determine if you need to make adjustments in your taper (e.g. rate, reduction interval, dose reduction technique).

[[...]]

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

Ty guys , the plan at this point is to stay at 1 mg daily until symptoms resolve . Mostly I’m dealing with anxiety and nausea (mild) , sweating .. etc . After I’m feeling confident to move forward , I will try 0.125mg odt , which is about 12.5% decrease . I will probably take 100 mg of gabapentin nightly , for sleep help . if this becomes intolerable , I will compound the ora sweet formulation you sent me   , and go even slower . I have a bunch of 2 mg tabs around and access to the equipment needed . I haven’t had a chance to look at the deprescribing guidelines yet , but I wil . Promise . Ty guys for getting back to me .. this is gonna be a wild ride . 

I tapered off 1.5 mg Klonopin over 7 months.  I was able to maintain a very high functioning demanding job till I got to 0.25 mg.  Things became unbearable at this point so I went on medical leave.  I probably could have updosed and tapered over a much longer time frame to keep my job but I personally was ready to make the sacrifice to be medication free and get my life back.  The stress the taper puts on the brain, mind, body is so significant that I believe we need ever ounce of energy to heal.  I also used the .125 mg dissolvable but they can be hard to find and I believe the manufacturer stopped making them as of recent? Anyhow, I used a compounded Klonopin 0.1mg/mL for the last bit.  Your MD should understand this and have no issue with a liquid taper going forward.  Pharmacy's charge a good bit to compound the Klonopin.  But I imagine with your skill and training you could do this in your kitchen?  

 

 

Honestly, I think gabapentin is fine.  As you know lyrica and gabapentin work the same way in calcium channels.  But instead of starting lyrica I would just increase the gabapentin, you're on a tiny dose that probably isn't doing anything as it's absorption is low.  I used gabapentin when things were real bad (up to 1200 mg at once) then just stopped.  I had no issues.  I think it is the lesser of evils and can be delt with later once you're off the Klonopin.

Or, just switch to valium and follow the Ashton manual.  Diazepam has a 2 mg tablet that is easier to make dose adjustments and go down slower.