How to taper off Xanax (alprazolam) 2.5mg/day and switch to Clonazepam (clonazepam)?

Tapering Alprazolam and Switching to Clonazepam

The safest approach to taper off Xanax (alprazolam) 2.5mg/day and switch to clonazepam is to substitute clonazepam and then gradually reduce the dose by 25% every 1-2 weeks to minimize withdrawal symptoms. 1, 2

Initial Substitution Phase

• Convert from alprazolam to clonazepam using an appropriate equivalence ratio. For alprazolam 2.5mg daily, substitute with approximately 2.5mg of clonazepam (1:1 equivalence ratio is commonly used for these two potent benzodiazepines) 3
• Divide the daily clonazepam dose into 2-3 administrations per day initially to maintain stable blood levels 3
• Monitor for 24-48 hours after substitution to ensure adequate symptom control and adjust dosing if needed 1

Tapering Schedule

• Once stabilized on clonazepam, begin a gradual taper by reducing the dose by 25% every 1-2 weeks 1
• For a 2.5mg starting dose of clonazepam, a sample tapering schedule would be:
  • Weeks 1-2: 2.5mg daily
  • Weeks 3-4: 1.875mg daily
  • Weeks 5-6: 1.4mg daily
  • Weeks 7-8: 1.05mg daily
  • Weeks 9-10: 0.75mg daily
  • Weeks 11-12: 0.5mg daily
  • Weeks 13-14: 0.25mg daily
  • Then discontinue 1

Monitoring and Adjustments

• Assess for withdrawal symptoms at each dose reduction using standardized assessment tools 1
• Common withdrawal symptoms include anxiety, insomnia, irritability, tremor, headache, nausea, and sensory hypersensitivity 2
• More severe withdrawal symptoms may include seizures, hallucinations, and delirium tremens 2
• If significant withdrawal symptoms occur, maintain the current dose for an additional week before attempting further reduction 1

Adjunctive Treatments

• Consider cognitive-behavioral therapy (CBT) during the taper, as it increases tapering success rates 1, 4
• For anxiety symptoms during tapering, non-benzodiazepine treatments such as specific antidepressants may be considered 1
• Implement sleep hygiene measures and possibly non-benzodiazepine sleep aids if insomnia becomes problematic 1

Important Considerations and Cautions

• Never abruptly discontinue alprazolam or clonazepam as this can lead to severe withdrawal including seizures, hallucinations, and in rare cases, death 2, 1
• The taper may need to be slower (10% reduction every 2-4 weeks) for patients who have been on high doses for extended periods 5
• Clonazepam's longer half-life (19-41 hours) compared to alprazolam makes it advantageous for tapering as it provides more stable blood levels and less severe interdose withdrawal 2
• If the patient is also taking opioids, coordinate care with all prescribers due to the increased risk of respiratory depression with concurrent use 1
• For patients struggling with the taper, slower reduction rates may be necessary, potentially extending the taper over several months 6
• Communicate with mental health professionals managing the patient to coordinate care and address underlying anxiety disorders 1

Special Situations

• For patients with a history of seizures or severe withdrawal symptoms, consider inpatient monitoring during the initial substitution phase 5
• For elderly patients or those with hepatic impairment, use lower initial doses of clonazepam and taper more gradually 7
• If withdrawal symptoms become intolerable despite slow tapering, temporarily increasing the dose to the previous level and then resuming a more gradual taper may be necessary 1