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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by cubbybear on February 3, 2004, at 1:02:45
I'd like to hear from anyone who had a rough time coming off the last .125 mg./day Klonopin, then succeeded! How did you do it? Tell me about your tapering schedule. Did anyone switch over to Valium and taper that way?
Posted by Chairman_MAO on February 3, 2004, at 8:36:05
In reply to Need Klonopin Taper Schedule from .125 mg., posted by cubbybear on February 3, 2004, at 1:02:45
There is no need to taper at this low of a dose. If it is unbearable to give up this last .125mg, try adding an anticonvulsant with GABAnergic activity, such as Gabitril or Depakote, titrate the dose up over a month, then discontinue the Klonopin. Neurontin or others might also help, but I'd try Gabitril first (assuming your doctor is comfortable with it, a lot aren't).
Posted by KellyD on February 3, 2004, at 8:36:41
In reply to Need Klonopin Taper Schedule from .125 mg., posted by cubbybear on February 3, 2004, at 1:02:45
If that's a daily dosage - you could go to every other day for a while then every third day then off. That's what was recommended to me IF I wanted to go off....which I don't. But, I know you do, so maybe try that. You could talk with your pharmacy person about a liquid solution which could be prepared.
I'm thinking if you want off benzo's and you are tapering from one with a long halflife, switching to Valium will just get you into another taper.. but, again, just my opinion.
If you are using benzo's for anxiety, did you find something effective for treatment? I don't question your desire to go off Klonopin but I would like to know your reason, if you would share that with me. If not, that's OK, too.
Kelly
Posted by Ame Sans Vie on February 3, 2004, at 11:44:16
In reply to Need Klonopin Taper Schedule from .125 mg., posted by cubbybear on February 3, 2004, at 1:02:45
I've certainly heard of plenty of people being able to gradually decrease their Klonopin (clonazepam) dose without incident until that final 0.125-0.25mg. Some people are just extremely sensitive to every little change that occurs in their biochemistry and thus require miniscule dose reductions to withdraw peacefully. Benzodiazepine withdrawal does not have to be at all uncomfortable, if you go about it properly.
The Valium switch is in all likelihood the best idea, though other long-half-life drugs such as Librium, Tranxene, Dalmane, Serax, Rohypnol (only outside the U.S., of course), or even phenobarbital are also sometimes employed. Depending on the drug used to substitute, here are what I've read and/or heard to be the best tapering methods:
--Valium (diazepam: half-life 20-100 hours [half-life of active metabolite is 36-200 hours]) is roughly 20 times less potent than clonazepam, so 2.5mg diazepam = 0.125mg clonazepam. Because of diazepam's extremely short duration of action, 0.5mg four times during the day and once before bed should be good to start you off (though the schedule should of course be adjusted according to your doctor's instructions as well as your own response to the drug -- the 0.5mg clonazepam = 10mg diazepam "rule" is not by any means universal, and it's important to find the dose that suppresses your withdrawal symptoms but doesn't over-sedate you). This dosage is easy to achieve with the 2mg diazepam tablets and a pill-cutter, though a liquid diazepam formulation would most certainly be best for the taper (cutting/shaving those small pills into eighths, sixteenths, and even further is both unreliable regarding dosing and extremely tedious!). Diazepam syrup typically contains 2mg/5ml of solution and can be diluted further to suit your needs. A 0.5mg/5ml dilution would probably be best in your case. The taper schedule for doses as low as yours may ideally be cutting out 0.5mg every 2-3 weeks, though with a 0.5mg/5ml solution, perhaps 0.2mg (2ml) every week would be easier on your system. How you accomplish this depends upon how often you administer the drug.
The following is an example of a tapering schedule using diazepam that my aunt found quite effective; I just (rather drastically) adjusted the dosage to suit your needs as she was withdrawing from 6mg Ativan (lorazepam; roughly equivalent to 30mg diazepam):
~First week-- 0.5mg (5ml) four times daily and once before bed {total dose -- 2.5mg = 0.125mg clonazepam}
~Second, third, and fourth weeks-- Substitute 0.3mg (3ml) for one of your *mid-day* doses each week until on a schedule of 5ml morning, 3ml three times during the day, and 5ml before bed. Lowering your morning dose at this point could cause jangled nerves to start off the day and lowering your bedtime dose could cause difficulty sleeping. {total dose @ week four -- 1.9mg = 0.095mg clonazepam}
~Fifth week-- Decrease morning dose to 3ml {total dose -- 1.6mg = 0.08mg clonazepam}
~Sixth week-- Decrease bedtime dose to 3ml {total dose -- 1.3mg = 0.065mg clonazepam}
~Seventh, eighth and ninth weeks-- Substitute 0.1mg (1ml) for one of your mid-day doses each week {total dose @ week nine -- 0.7mg = 0.035mg clonazepam}
~Tenth week-- Decrease morning dose to 0.1mg (1ml) {total dose -- 0.6mg = 0.03mg clonazepam}
~Eleventh week-- Decrease bedtime dose to 0.1mg (1ml) {total dose -- 0.5mg = 0.025mg clonazepam}
~Reduce dosing to 0.4mg (4ml) total per day at the twelfth week (preferably by carefully measuring out 0.8ml per dose), 0.3mg (3ml) per day at the thirteenth week (0.6ml per dose), 0.2mg (2ml) per day at the fourteenth week (0.4ml per dose), then 0.1mg (1ml) per day at the fifteenth week (0.2ml per dose) {total dose @ week fifteen -- 0.1mg = 0.005mg clonazepam}
~At this point, at 1/200mg clonazepam equivalent, quitting cold turkey should be a breeze; if not, you might try decreasing the dose even further to 0.05mg (0.5ml daily; 0.1ml per dose), or simply dropping a dose each week until withdrawn.
--Using any other benzodiazepine or phenobarbital to withdraw will require the same basic taper schedule, but differences in dosage and administration.
~Librium (chlordiazepoxide HCl; half-life 5-30 hours; half-life of active metabolite 36-200 hours) will probably need to be taken five times daily, just like diazepam. However, it is about 2.5 times less potent than diazepam, so 0.125mg clonazepam = 2.5mg diazepam = 6.25mg chlordiazepoxide HCl.
~Tranxene (clorazepate dipotassium; half-life of active metabolite 36-200 hours) can usually be administered three times daily and is about 1.5 times less potent than diazepam. Thus 0.125mg clonazepam = 2.5mg diazepam = 3.75mg clorazepate dipotassium.
~Dalmane (flurazepam; half-life of active metabolite 40-250 hours) is rarely used as it is primarily a sleep aid. However, its long half-life lends itself to utility in some situations. It can be taken three times daily and is about three times less potent than diazepam -- 0.125mg clonazepam = 2.5mg diazepam = 7.5mg flurazepam.
~Serax (oxazepam; half-life 3-25 hours) is only used in the elderly or when liver dysfunction is an issue as it is not metabolized through the liver like most other benzos. Beyond that it is definitely not a proper substitution for withdrawal. For the record, it must be taken four-five times daily, and is about two times less potent than diazepam -- 0.125mg clonazepam = 2.5mg diazepam = 5mg oxazepam.
~Rohypnol (flunitrazepam; half-life 18-26 hours; half-life of active metabolite 36-200 hours), the infamous "Roofie", is used occasionally outside the U.S. due to its long half-life, but considering it's short duration of action and high potency, I would think the taper would be pretty similar to a withdrawal from clonazepam, or perhaps Halcion (triazolam).
~Phenobarbital, a long-acting barbiturate, seems to be favored by some doctors (especially in the U.S.) to manage benzo withdrawal. Once- or twice-daily dosing is usually sufficient. Most sources consider diazepam to be three times more potent than phenobarbital, so 0.125mg clonazepam = 2.5mg diazepam = 7.5mg phenobarbital. The smallest commercially available tablet size (in the U.S., at least) is 8mg, though a 15mg/5ml elixir is available (which I assume one could adulterate with an acceptable diluent, as with diazepam syrup, to make smaller doses easier to measure).
While Depakote, Gabitril, Neurontin, and other similar GABAergic drugs may help during the withdrawal, it is my opinion that they should never, ever be used as a substitute for a careful taper. My first doctor attempted to withdraw me from 4mg of Xanax daily (about equivalent to 2mg Klonopin) using solely Depakote. After several months on this dose of Xanax, he started me on the Depakote and began titrating the dose upward without informing me of his intentions; then at one of our next appointments, he just refused to write a prescription for Xanax saying that I had already been on it too long and that the Depakote would prevent withdrawal. What a crock! Those next few weeks were some of the worst hell I've ever been through. I was numb all over, I couldn't taste anything, I was suicidal but too physically weak to even move -- literally. I just can't believe I made it through without having a seizure. And oddly enough, it was the GABAergic anticonvulsant Gabitril which induced my first-ever seizure in November of '02 that nearly killed me! My first 8mg dose put me into a 30 minute catatonic state (during which time my little sister, thank god, had the sense to dial 911), followed by three hours of status epilepticus which the hospital was unable to arrest. I finally awoke eight hours after my dose of Gabitril; I was intubated in the E.R. with no idea what day (or year) it was, and I didn't recognize my family doctor when he came to see me. Scary stuff. I haven't heard of this happening to anyone else, but I'd certainly be wary of putting a drug into my body which could cause convulsions while already being at a high risk of seizures due to benzo withdrawal. Besides, as far as using Gabitril as a replacement GABAergic, it mostly inhibits the reuptake of GABA-B; it's GABA-A that is the primary target of benzodiazepines.
Of course, this is just meant as a guide; your doctor, and ideally yourself as well, will have the final say in how you go about this. I'm sorry the whole post is so long, technical, and mind-numbing, but as this is a topic that I have some experience with and which can literally kill you if not well-understood, I felt the need to personally address it to the very best of my ability. Best of luck to you, and let us know how it goes!
Michael
Posted by Chairman_MAO on February 3, 2004, at 21:19:13
In reply to Re: Need Klonopin Taper Schedule from .125 mg., posted by Ame Sans Vie on February 3, 2004, at 11:44:16
>
> While Depakote, Gabitril, Neurontin, and other similar GABAergic drugs may help during the withdrawal, it is my opinion that they should never, ever be used as a substitute for a careful taper.They shouldn't be used as a substitute. I'm not a neurologist, but I cannot imagine that anyone without neurological problems could EVER need tapering past 0.125mg. Sure, there may be residual psychiatric issues past 0.125mg, but this is a given; post-acute benzodiazepine withdrawl symptomology can last for 6 months or perhaps longer. But residual psychiatric symptoms do not require nor are adequately treated by giving virtually homeopathic doses of benzodiazepines.
>My first doctor attempted to withdraw me from 4mg of Xanax daily (about equivalent to 2mg Klonopin) using solely Depakote.
4mg of xanax is equivalent to _8mg_ of Klonopin. That is malpractice.
After several months on this dose of Xanax, he started me on the Depakote and began titrating the dose upward without informing me of his intentions; then at one of our next appointments, he just refused to write a prescription for Xanax saying that I had already been on it too long and that the Depakote would prevent withdrawal. What a crock! Those next few weeks were some of the worst hell I've ever been through. I was numb all over, I couldn't taste anything, I was suicidal but too physically weak to even move -- literally. I just can't believe I made it through without having a seizure.
The Depakote probably prevented the actual convulsions. However, the crazy neuropathies that you are describing feel a lot like what I felt when I tried to detox myself from Valium using phenobarbital. Don't forget that there are peripheral as well as CNS benzodiazepine receptors. I am truly sorry you had to suffer such a sadistic/incompetent doctor.
> And oddly enough, it was the GABAergic anticonvulsant Gabitril which induced my first-ever seizure in November of '02 that nearly killed me! My first 8mg dose put me into a 30 minute catatonic state (during which time my little sister, thank god, had the sense to dial 911), followed by three hours of status epilepticus which the hospital was unable to arrest.How soon after your benzodiazepine withdrawl was this?
> I finally awoke eight hours after my dose of Gabitril; I was intubated in the E.R. with no idea what day (or year) it was, and I didn't recognize my family doctor when he came to see me. Scary stuff. I haven't heard of this happening to anyone else, but I'd certainly be wary of putting a drug into my body which could cause convulsions while already being at a high risk of seizures due to benzo withdrawal.
No one that's been taking 0.125mg of Klonopin for a while is at risk for anything even near a convulsion. 0.125mg probably couldn't be distinguished from placebo in benzo-naive people.
> Besides, as far as using Gabitril as a replacement GABAergic, it mostly inhibits the reuptake of GABA-B; it's GABA-A that is the primary target of benzodiazepines.It it is a GABA reuptake inhibitor. Thus, it increases the amount of GABA at all GABA receptors (GABA-A & B).
Posted by cubbybear on February 4, 2004, at 0:45:10
In reply to Re: Need Klonopin Taper Schedule from .125 mg., posted by KellyD on February 3, 2004, at 8:36:41
>
> If you are using benzo's for anxiety, did you find something effective for treatment? I don't question your desire to go off Klonopin but I would like to know your reason, if you would share that with me. If not, that's OK, too.
> KellyI don't mind you asking--many people are curious about this! You could also look under my second post under "Oh God--Parnate Poopout?" of a few days ago. Originally, I was prescribed Parnate for insomnia, which was a side effect of my severe depression. When the depression went into remission last March, I decided I wanted to stop the Klonopin, and I've deliberately stretched it out this long to avoid withdrawal problems. I mentioned some other reasons for wanting off Klonopin in the other thread.
Thanks for your tapering advice.
Posted by cubbybear on February 4, 2004, at 1:44:26
In reply to Re: Need Klonopin Taper Schedule from .125 mg., posted by Ame Sans Vie on February 3, 2004, at 11:44:16
Hi Michael,
Your post is definitely the most thought-out and helpful I've ever seen on this subject; I know that your many posts on this board have been more helpful and educated than the advice of some of the most brlliant (??) doctors. I'd just like to update you on what's happened over the past 24 hours regarding my tapering (BTW, I took another .125 mg. dose of Klonopin last night before bed, slept well, and am not feeling anxious today).
I've been perusing the tapering guidelines available on the benzo.org.uk website, which solidly advocates switching to the equivalent dosage of Valium (diazepam) and then tapering at the rate of 1 mg. every 1-2 weeks when Klonopin dosage is .125 mg./day. When I first came across this website, I was turned off by its anti-benzo tone and figured that it was the product of some hysterical benzophobes.
I now believe that even though the Ashton group is very much opposed to benzo usage beyond 4 weeks, they seem to have the expertise to offer some very helpful advice on tapering off. Not only that, their suggestions on having your pharmacy make up special capsules with ultra-low doses are quite intriguing; and I would definitely inquire about that if I run into problems with the dose reduction schedule of 1 mg. (Valium) every 1-2 weeks.
I don't believe that liquid Klonopin is available at Bangkok Hospital, although I didn't inquire for sure about it.
If you or anyone else is wondering about the drug professionals' expertise here in "The Land of Smiles," I can tell you that there are some incompetent doctors on this side of the Pacific as well. My regular pdoc is available only on Saturdays and the "semi-emergency" of Monday's withdrawal anxiety necessitated my seeing a different guy yesterday. I brought along my graph that details exactly how my tapering has progressed from 3.75 mg./day, and I described what I felt on Monday after several alternating days on 0 mg.
Well, this guy screwed up on 2 major points: a) he was insistent that my anxiety was a panic attack that is common in middle-age people who get depressed; he said that it was definitely not withdrawal anxiety from my benzo dose reduction; b) worse yet, he was insistent on my using his own diazepam-clonazepam equivalency figure, which is way off what I've seen published on 2 separate websites. Even the hospital pharmacist showed me a book that they use which states the widely-accepted equivalency of 5 mg. diazeam to .25 mg. clonazepam. If I want to be fool enough to go with the doctor's equivalency, I could be bringing plenty of misery upon myself, so I'm going to toss out his figures and use the widely-accepted one above.
The only good thing to come out of this disconcerting session is that the guy wrote me out a script for 40 tabs of 2 mg. diazepam, which I plan to cut into halves (for 1 mg.) and quarters (for .5 mg.) with my pill cutter, and see how it goes.
Meanwhile, I want to thank you again for your time-consuming and most considerate efforts at typing out your post. I will definitely keep a printed copy in the event that I have to taper even slower.
cubbybear
This is the end of the thread.
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