“Tapering Clonazepam using Par ODTs.”

[[Ho...]]

I am interested in tapering off Clonazepam. I take PAR brand of 1.25mg ODT twice a day. 
Questions:: 1. How do I taper when I take it twice a day?  I’ve tapered ADs before but only took them once a day. 
                    2. If I use a compounded liquid to taper, can I specify I want PAR brand liquid?
 

I really need to get off this as I’ve been in tolerance withdrawl for over 3 years and suffering many symptoms; also, I’m quite concerned that it has affected me cognitively  

thank you

           

[[Li...]]

Hello @[Ho...].  Thank you so much for creating your own Taper Strategies Planning topic/thread!

Before I address your questions (rest assured that tapering multiple doses a day is quite do-able), I have two for you:

(1) Have you seen the alert about the nationwide recall of one lot of the Par ODTs?  If not, I’ve included a link to a post on this below.

(2) Are you experiencing interdose withdrawal?  In other words, do your withdrawal symptoms increase as the time of your next dose approaches?  Or, do your withdrawal symptoms remain about the same irregardless of when you take a dose?

 

[[Li...]]

Hello again @[Ho...].

9 hours ago, [[H...] said:

I take PAR brand of 1.25mg ODT twice a day. 

Did you mean to write 0.125mg instead of 1.25mg?  

9 hours ago, [[H...] said:

1. How do I taper when I take it twice a day?  I’ve tapered ADs before but only took them once a day. 

Here’s one possible approach for your consideration.  

Decide on a taper rate and interval to trial. Let’s say 10% per month.

Calculate the total reduction amount. For example, 10% of 0.25mg is 0.025mg.

If you wish to daily microtaper that amount over 30 days, you could alternate between reducing your doses by 0.001mg a day and then holding at your target dose for 5 days as follows:

Day 1
Dose 1: 0.124mg
Dose 2: 0.125mg 

Day 2
Dose 1: 0.124mg
Dose 2: 0.124mg

Day 3
Dose 1: 0.123mg
Dose 2: 0.124mg

Day 4
Dose 1: 0.123mg
Dose 2: 0.123mg

etc.

Days 26 - 30 
Dose 1: 0.1125mg
Dose 2: 0.1125mg

9 hours ago, [[H...] said:

2. If I use a compounded liquid to taper, can I specify I want PAR brand liquid?

This would be a question for the compounding pharmacist.  They may or may not be willing to do this.

Does your prescriber currently include a DAW (Dispense As Written) order for the Par ODTs on your prescription?  If so, that might make the compounder more amendable to this request.

[[Ho...]]

Yes, .125mg ODT twice a day

Thanks for info about the PAW order; I will check. 
A quick background: I tapered Paxil too quickly in 2020 over a year using tapering strips  I thought that was enough time and had never thought to check online about it  needless to say in 2021 I entered hell!

I was hospitalized twice and cycled through all kinds of drugs because not one doctor out of many suggested it might be too fast taper of Paxil.

I have not been well in 2021, 2022, most of 2023.  During that period I stabilized my Clonazepam at .125mg  I ended up on Mirtazapine which I’ve tapered to 2.25mg from 7.5mg and Nortriptylin 50mg. I started tapering Mirtazapine because it was causing Orthostatic hypotension and my doctor wanted me off of it.

I really want off Clonazepam because I believe it’s causing cognitive problems (76 yrs old) and keeps me in state of anxiety, and does not do what it once does. For that reason I think I am in tolerance withdrawal                                                
I believe the bedtime dose helps me sleep but morning dose does nothing helpful.

I’ll look at taper schedule you sent me.  Thank you for so much for your help.

 

[[Ho...]]

Further thinking. - how would I taper dose if I’m on an ODT (Orally Disintegrating Tablet)?

[[Li...]]

I’m sorry you had a bad experience using Tapering Strips to taper Paxil, @[Ho...].  Sadly, you are not the first member to report issues (e.g. one member crashed and burned b/c the hyperbolic tapering ‘trajectory’ recommended by the pharmacist was too fast and reductions were made in just one of their daily lorazepam doses instead of across their multiple daily doses).

Thank you for sharing your medication history with us. This is very important information! 

Per The Maudsley Deprescribing Guidelines (Horowitz & Taylor, 2024, pp. 350-352), you are presenting with several risk factors indicating the need for a cautious approach to withdrawal (see Note 1 below).

The example taper schedule I gave you in my previous post was for a 10% reduction in dose over 30 days from your initial starting total daily dose of 0.25mg taken in two doses of 0.125mg.

Horowitz and Taylor suggest patients with one or more ‘high risk’ characteristics, start with a 5% or less trial reduction.

For your consideration, here’s an example of a trial taper of 4% over 14 days followed by a hold to gauge your response.  It assumes the use of a compounded liquid with a concentration of 0.1mg/mL:

Transition Period (see Note 2 below)
1.25mL, 1.25mL

Day 1
1.24mL, 1.25mL

Day 2
1.24mL, 1.24mL

Day 3
1.23mL, 1.24mL

Day 4
1.23mL, 1.23mL

etc

Days 15 - 22
Hold at 1.20mL, 1.20mL

Note 1:  Risk factors include evidence of tolerance, experience of interdose withdrawal, past history of severe withdrawal, older or otherwise physically frail, repeated cycles of benzodiazepine — or other psychiatric medications — use and cessation.

Note 2: I strongly suggest you include a transition period when switching from a solid to a liquid dosage form. You could begin by switching one of your daily doses to liquid and then waiting a few days to see how you respond.  If all is well, you could then switch the other dose to liquid and hold again to gauge response. During the transition period you would keep your doses constant at 1.25mL (assuming a 0.1mg/mL liquid). You would not make any reductions in dose). 

[[Ho...]]

I deeply appreciate your very clear explanation and suggestions to begin taper. 
I just want relief. Anxiety and crying everyday plus  I have pain in my body and inflammation in brain as well. 
I will contact my doctor to request the DAW order. 

 

[[Li...]]

You’re welcome @[Ho...].

Have you located and vetted a compounding pharmacist who has expertise in preparing liquid formulations of clonazepam?

 

[[Ho...]]

Compounding pharmacy said they have experience preparing liquid Clonazepam. What else would I inquire about?

[[Li...]]

That’s encouraging news, @[Ho...].  Off the top of my head, questions I would ask include:

• How much experience do you have preparing this compound? Have patients who used it (or something similar) had any issues with it?  If so, what?
• What formulation  (‘recipe’) do you use?    Does it produce a suspension or a solution?  Has it been tested for potency and stability?  What is its concentration?
• What is the source of the active ingredient?  Bulk powder or regular tablets? Would it be possible to prepare the formulation using Par clonazepam ODTs?
• Will you supply oral syringes of the appropriate capacity* as well an adapter cap for the bottle?
• Will you provide me with instructions on how to use the adapter cap and oral syringe properly to measure my target doses?
• If needed, will you work with my prescriber to help them write the prescription properly?
• What steps will you take to ensure that my compounded liquid is consistent from batch to batch?
• What will the cost be per fill?  Will my insurance cover any of this? Do you have a discount program?

* For the example, assuming a liquid with a concentration of 0.1mg/mL as shown in the above example,  you would need a 1mL oral syringe with graduation marks every 0.01mL and a 0.5mL oral syringe, also with graduation marks every 0.01mL. 

 

[[Ho...]]

Compounding pharmacy said they have experience preparing liquid Clonazepam. What else would I inquire about?

[[Ho...]]

Wow! I had no idea about what to check w compounding pharmacy. 
Thank you for that extensive list.