“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. 

[[Li...]]

Hello @[Ho...].  

I’ve copied the post you made to @[je...]’s Success Stories below followed by the Personal Message (PM) you sent me (per our community guidelines, PM is only to be used for ‘chat chat’ not for tapering or withdrawal related support).  I’ve also included snippets from your previous posts so we’ll have a better sense of your case history. 

My questions are:

• Were you stable and functional on a dose of 0.125mg clonazepam orally disintegrating tablets (ODTs) taken twice a day?  In particular, how was your sleep?  
• Are you still taking other psychotropic medications?  If so, what?  If not, when/how did you discontinue them?
• What are the ingredients in the compounded liquid?
• What is the concentration of the compounded liquid?
• How many milliliters of the compounded did you ingest to achieve a dose of 0.125mg?

Quote

I am in interdose , tolerance withdrawal and in PAWS from too fast trigger of Paxil in 2020 

it’s been a nightmare

I decided to start tapering Clonazepam in hopes of saving my cognitive function and also to hopefully eliminate this Benzo belly.  
 
currently taking .125mg as Orally Disintegrating Tablet. Soto taper I had to get compounding pharmacy to make a liquid. Since I was going from pill to liquid I was advised to continue at .125 to see how my system handled to change for pill to liquid.  

I have done that for 3 nights and every night I wake up around 2 with high anxiety and the inability to go back to sleep.  
 
did you have any problem switching from pill to liquid?

Quote

 

now need advise on what to do. Go back to ODT for couple of days and try again?

I can only think it’s because the ingredients in ODT are different than powder pharmacy  used to make my solution. 
I spoke w another pharmacy who said they could take Clonazepam regular table from same manufacturer of ODT and make a solution. When I look up ingredients of ODT and regular tablet I see the ingredients are different. So does that gain me anything?

 

History

May 17, 2019
Been on Klonopin for 20 yrs but rarely took it, maybe 1/4 - 1/2 .5mg tabs a month. But last 4 months had major depressive episode and prescribed 1/2 tab twice a day.

I have been in extreme angst and depression daily during the past 4 months and am now convinced the problem is the Klonopin. I am on Prozac 40mg.

Right now I am taking max of .5mg Klonopin daily but I take it as needed, no set time but it’s pretty ineffective no matter when I take it  But I am besieged with anxiety night and day with insomnia, sleeping only 2 hrs before awakening in sweats and burning hands, anxiety.

October 20, 2021
I am meeting with a new doctor to forge a plan to get off Klonopin and Antidepressants. It all sneaked up so suddenly and I’m quite frightened. I don’t have a lot of support and that a huge problem because I’ve become agoraphobic and can barely care for myself.  I’m 74 years old and hope I have enough time left to get my life back.

Anyhow, I’ve been on Klonopin on and off for 20 years. Now on .125mg twice a day. Also on Sertraline 25mg, Mirtazipine 7.5mg and Pregabalin 50mg.

I want to get off Mirtazipine for sure. I am considering getting tapering strips from The Netherlands. I used them when I tapered off Paxil.

I have been on .125 mg clonazepam twice a day for 7 months.  Last 2 months I have been experiencing what I think are withdrawal symptoms. I have insomnia, hypersensitive, tremors, burning pain, agitation, severe anxiety, etc.

July 22, 2024
I currently take PAR brand .125mg ODT. 

 

[[Ho...]]

I was stable and functional on 125 Clonazepam. (I still have bad digestive issue and Benzo belly as well as wakening about 4:30-5 every morning in state of dread which I understand is natural cortisol surge 

I take .225 mg Mirtazipine mg qd and Nortriptylin 50 mg qd. 
 

from pharmacist:

Below are the ingredients for the tablets and we used 5-1/2 tablets in your formula.   Attached is the ingredient list for the  liquid base, suspendit.

Clonazepam Tablets, USP, a benzodiazepine, is available as scored tablet with debossing Λ containing 0.5 mg of clonazepam and unscored tablets with debossing Λ and Λ containing 1 mg or 2 mg of clonazepam respectively. Each tablet also contains lactose monohydrate, polyethylene                                                                                                                                               

glycol, microcrystalline cellulose, croscarmellose sodium and magnesium stearate, with the following colourants: 0.5 mg-FD & C Yellow 6 Al Lake, D & C Yellow 10 Al Lake; 1 mg-FD & C Blue 1 Al lake and FD & C Blue 2 Al lake

Chemically, clonazepam is 5-(2-chlorophenyl)-1,3-dihydro-7-nitro- 2H-1,4-benzodiazepin-2-one. It is a light yellow crystalline powder.

From pharmacist:

list of ingredients in liquid base they used

Ingredients
PCCA #30-4825 Base, PCCA SuspendIt®
(Formerly known as SuspendAllTM)
 Water
Amorphophallus Konjac Root Powder Siraitia Grosvenorii (Monk) Fruit Extract Xanthan Gum
Potassium Sorbate
Sodium Benzoate
Citric Acid
Disodium EDTA

Concentration .1mg /ml

Because dose was so low pharmacist directed me to take 10ml from their formulation, add 90ml, and then take 12.5 ml as a dose  

 

my current PAR ODT tablet of .125 ingredients

 

INACTIVE INGREDIENTS

Ingredient NameStrength

ASPARTAME (UNII: Z0H242BBR1)  

CROSPOVIDONE (UNII: 2S7830E561)  

MAGNESIUM STEARATE (UNII: 70097M6I30)  

MANNITOL (UNII: 3OWL53L36A)  

SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  

SORBITOL (UNII: 506T60A25R)  

SODIUM LAURYL SULFATE (UNII: 368GB5141J)  

TALC (UNII: 7SEV7J4R1U)

 

 

I think this is all you asked for. Thank you so much. 

 

[[Li...]]

Thank you for the additional information, @[Ho...]. This will help us troubleshoot what might be going on.  

What stands out to me is that the pharmacist changed both your dosage form and manufacturer.  Instead of using your Par ODTs to make the clonazepam suspension, they used standard tablets from a different manufacturer.  From the description provided it sounds like Advagen.  

Advagen is a relatively new player in the generic clonazepam space (ANDA is dated 4/2022).  Some individuals have experienced issues with it — perhaps due to the excipients used, a difference in the amount of clonazepam in the Advagen tablets compared to those from the manufacturer they had been using, general quality control issues, etc.

Have you had negative reactions to any of the ingredients used in the Advagen in the past?  

How about the ingredients in SuspendIt, the suspending vehicle?

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

Because dose was so low pharmacist directed me to take 10ml from their formulation, add 90ml, and then take 12.5 ml as a dose  

Add 90mL of what to what?  Did you:

1. measure 10mL of the compounded liquid
2. add 90mL of water
3. ingest 12.5mL of the compound/water mixture

What did you do with the remaining compound/water mixture?  Did you use this for your next dose or doses?  Or, did you make a fresh batch of the compound/water mixture for each dose or day?

Did the pharmacist stress the importance of shaking the compounded liquid  as well as the liquid/water mixture well before measuring your dose?

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

every night I wake up around 2 with high anxiety and the inability to go back to sleep.

When you were taking the ODTs, you indicated you were waking up at every morning at 4:30-5am.  It’s possible you are waking up earlier due to a slight difference in the bioavailability of the compounded liquid and the ODTs. It’s also possible the compounded liquid contains a slightly different amount of clonazepam than the ODTs. It also could be due to something else (e.g. anxiety over the change in dosage form) or a combination of factors.  

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

I spoke w another pharmacy who said they could take Clonazepam regular table[t] from same manufacturer of ODT and make a solution.

Par does not make a regular clonazepam tablet.  Was the pharmacist proposing to use bulk powder (i.e. the pure active drug substance or Active Pharmaceutical Ingredient to make a liquid? 

Options for you to consider:

• Continue to use the current compounded liquid to see if you begin to adjust to it.
• Find out more about the ingredients of the liquid the second compounding pharmacist is proposing to use.  If they plan to use bulk powder as the drug source (as opposed to tablets or ODTs) and have a formulation for a solution (not a suspension), trial that.
• Try making a do-it-youself liquid using the Par ODTs.  Some individuals make a suspension using water, others use whole fat homogenized milk to make an emulsion.

[[Ho...]]

I have decided to take your advice and make my own liquid from the current PAR brand .125 ODT. The downside is that solution will not be stable and therefore will have to make it daily. I guess the positive is that it’s easier to travel with it. 
 

I’m  trying to figure out how much water to mix it with so I can easily measure 1.24mg, 1.23 mg etc.  They are so small that I need to have enough solution that a syringe can measure. 
 

I’d appreciate any suggestions. 

[[Li...]]

55 minutes ago, [[H...] said:

I have decided to take your advice and make my own liquid from the current PAR brand .125 ODT.

Just to clarify, I did not advise you to make your own liquid, @[Ho...].  I simply presented this to you as an option for your consideration. (Giving prescriptive advice is a violation of community guidelines.)

My personal opinion is that using a professionally compounded liquid is preferable to going the do-it-yourself (DIY) route.  However, I will be happy to share my thoughts on the pros and cons of the DIY approach as well as my suggestions on how you might implement it tomorrow  afternoon or evening (it’s getting late here and I have morning appointments). 

In the interim, I hope other members who have experience making DIY liquids will offer their input.

[[Ho...]]

I apologize. I didn’t mean advice. I know you were just identifying different ways  to approach taper. 
 

in my post I meant so I can easily measure .124mg, .123mg, .122mg, etc 

[[Li...]]

Hello @[Ho...].  It’s been a long, busy day here.  

No apology needed.  I just wanted to clarify our community guidelines re: giving prescriptive advice for you.

Have you considered using whole fat, homogenized milk to make a do-it-youself liquid with the clonazepam ODTs?  A well-known and well-respected taper coach uses this approach with several of her clients.  We also have several members who have used this approach successfully.  

The rationale for using milk is explained in The Maudsley Deprescribing Guidelines as follows:

“Benzodiazepines are more soluble in oil or fat than in water (Macheras et al 1990).  When mixed with full-fat homogenized milk, some or all of the drug will dissolve in the milk fat.  This should form an evenly dispersed emulsion when shaken vigorously …..” (Horowitz & Taylor, 2024, p. 341)

In contrast, when you disperse a clonazepam tablet/ODT in water, the resulting liquid is a short-lived suspension.  It is a suspension b/c very little or none of the drug is dissolved in the water (clonazepam is ‘practically insoluble’ in water).  It is short-lived, b/c water is a poor suspending vehicle due to its low viscosity (consequently, undissolved particles of drug and excipient do not remain suspended for very long).

Re: your question …

If you wish to reduce your dose by 0.001mg at a time, one option would be to make a liquid with a concentration of 0.001mg/mL.  To do this, you could disperse one 0.125mg ODT in 125mL of either milk or water.  

In both cases, it will be important to:

(1) Give yourself time to adjust to the change in dosage form from ODT to liquid before you begin reducing your dose.  For example, you could begin by switching one of your two daily doses to liquid. If all is well after several days, you could switch your second dose to liquid and again wait 7-12 days to see how you respond.  If all is well, you could then begin reducing your dose.

(2) Shake the liquid well before measuring your dose to ensure that any particles of undissolved drug are distributed as evenly as possible throughout the liquid. 

 

 

[[Ho...]]

Thank you again for all the guidance. 
I currently dissolve an AD, Mirtazapine, in water but think I may switch to  milk after your explanation because I know it doesn’t dissolve well. I may actually get some increase in benefit from it. 

If milk will benefit me I’ll definitely use that w taper. 
And, yes, I will stick w current dose of .125mg for a number of days converting it to liquid slowly. 

[[Li...]]

You’re welcome, @[Ho...].

Am I understanding correctly that you are considering using milk to make a do-it-yourself (DIY) mirtazapine liquid?  If so, please do your own research about whether or not this drug is soluble in milk.  The folks at SurvivingAntidepressants.org or the Mirtazapine: Peer Support, Withdrawal, Recovery group on Facebook might be able to assist.

Re: making a DIY liquid with clonazepam ODTs and milk, here’s a link to an old thread about the process used by one of our members:

https://benzobuddies.org/topic/222816-milk-as-a-liquid-solution/#findComment-2938504

 

[[Ho...]]

Did first combo of .125ODT tablet and milks for morning dose. Tonight just took tablet as usual. 
 

By the way, I have developed cognitive issues and my doctor would like me off this ASAP due to dementia concern. I explain that I have to go very slow. 
I was thinking after 2 months, depending on symptoms, I might be able to increase taper percent. 
is there any “known” way to get off Benzo sooner?

Also, Dr. suggested I try Naltrexone to support my body through taper since it’s used successfully for Opioids.

Anynthoughts on these 2 areas?

[[Li...]]

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

I was thinking after 2 months, depending on symptoms, I might be able to increase taper percent. 

You might.  Or, you might not, @[Ho...]. The only way to know what taper rate you will be able to tolerate during any given phase of your taper is via self-experimentation.  Per Mark Horowitz: “Taper as fast as you can but as slow as you need to.”

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

is there any “known” way to get off Benzo sooner?

What do you mean by “known”?  For example, are you asking if there are evidence-based protocols for rapid discontinuation?

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

Also, Dr. suggested I try Naltrexone to support my body through taper since it’s used successfully for Opioids.

Have you tried using our search engine to locate past topics (threads) and posts on this topic?  You could also start your own New Topic about naltrexone on this forum:

Benzodiazepine Withdrawal, Use & Recovery

 

[[Ho...]]

Did first combo of .125ODT tablet and milks for morning dose. Tonight just took tablet as usual. 
 

By the way, I have developed cognitive issues and my doctor would like me off this ASAP due to dementia concern. I explain that I have to go very slow. 
I was thinking after 2 months, depending on symptoms, I might be able to increase taper percent. 
is there any “known” way to get off Benzo sooner?

Also, Dr. suggested I try Naltrexone to support my body through taper since it’s used successfully for Opioids.

Anynthoughts on these 2 areas?

[[Ho...]]

Just wishful thinking on my part that I could get off quicker. I’ll do some research on Naltroxone. 
I used to be smart and quick thinking until 4 years ago when I the crash happened.