What is the protocol for tapering off clonazepam (Klonopin)?

From the Guidelines

To taper off clonazepam safely, I recommend a gradual reduction of 25% of the daily dose every 1-2 weeks, depending on the patient's current dose and individual response. This approach is supported by the most recent and highest quality study, which suggests that a gradual reduction of benzodiazepines can be effective in minimizing withdrawal symptoms 1. For example, if a patient is taking 1mg twice daily, reduce to 0.75mg twice daily for 1-2 weeks, then 0.5mg twice daily for 1-2 weeks, and continue this pattern until completely off the medication.

Key Considerations

• The slower the taper, the less likely withdrawal symptoms will occur, and patients should be monitored for symptoms including anxiety, insomnia, irritability, tremors, sweating, and in severe cases, seizures 1.
• The taper schedule may need adjustment based on how the patient tolerates each reduction, and some patients may require an even more gradual taper extending over several months 1.
• It's essential to emphasize that patients should never stop clonazepam abruptly, as this can lead to severe withdrawal symptoms, including rebound anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death 1.
• The tapering process is necessary because clonazepam affects GABA receptors in the brain, and the brain needs time to adjust to functioning with decreasing levels of the medication.

Additional Strategies

• Consider using adjunctive pharmacological interventions, such as carbamazepine, pregabalin, or antidepressants, to facilitate tapering and mitigate withdrawal symptoms, although the evidence for these interventions is limited 1.
• Nonpharmacological psychosocial interventions, such as cognitive-behavioral therapy, problem-solving, and supportive psychotherapy, can also be effective in reducing benzodiazepine use and mitigating withdrawal symptoms 1.
• Education and self-empowerment are crucial in facilitating successful benzodiazepine tapering, and patients should be informed about the risks and benefits of tapering 1.

From the FDA Drug Label

To reduce the risk of withdrawal reactions, use a gradual taper to discontinue clonazepam or reduce the dosage (a patient-specific plan should be used to taper the dose) The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose Abrupt discontinuation or rapid dosage reduction of clonazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening. To reduce the risk of withdrawal reactions, use a gradual taper to discontinue clonazepam or reduce the dosage

The protocol for tapering off clonazepam (Klonopin) is to use a gradual taper to discontinue the drug or reduce the dosage, with a patient-specific plan to taper the dose 2, 2, 2.

• The tapering plan should aim to minimize the risk of withdrawal reactions, which can be life-threatening.
• Abrupt discontinuation or rapid dosage reduction should be avoided.
• The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose.
• It is essential to monitor patients closely for signs and symptoms of respiratory depression and sedation during the tapering process.

From the Research

Protocol for Tapering Off Clonazepam

• The protocol for tapering off clonazepam involves gradually reducing the dosage to minimize withdrawal symptoms 3.
• A study published in the Journal of Clinical Psychopharmacology recommends reducing the dosage of clonazepam by 0.5 mg per 2-week period until 1 mg per day is reached, followed by a decrease of 0.25 mg per week 3.
• The mean dosage at the start of tapering was 2.7 +/- 1.2 mg/d, and 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol 3.

Withdrawal Symptoms

• Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches 3.
• Withdrawal seizures have occurred with short, medium, and long half-life benzodiazepines, if discontinued abruptly, and can range from a single episode to coma and death 4.
• Symptoms associated with benzodiazepine use, tapering, and discontinuation were numerous and ranged from symptoms such as anxiety, insomnia, and nervousness to digestive problems, irregular heart rhythms, uncontrollable anger, photosensitivity, balance problems, and others 5.

Tapering and Discontinuation

• Benzodiazepine dose tapering can be done faster in a hospital setting in high-dose abusers, but must be done more slowly in the outpatient setting in therapeutic dosage users 4.
• A fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification was found to be safe and effective, with no seizures, falls, or injuries reported 6.
• The trajectory of those who taper or discontinue benzodiazepines is unpredictable, and many patients experience a range of protracted and severe symptoms, even years after benzodiazepines were completely discontinued 5.