What is the recommended tapering schedule to discontinue Klonopin (clonazepam) in a patient taking 0.5mg daily and 1mg at bedtime?

Clonazepam Discontinuation Plan for AMA Discharge

For a patient taking clonazepam 0.5mg daily and 1mg at bedtime (total 1.5mg/day), reduce the dose by 0.25mg every 1-2 weeks, prioritizing the bedtime dose first, until complete discontinuation is achieved over approximately 6-12 weeks. 1

Specific Tapering Schedule

Week 1-2: Reduce bedtime dose

• Morning: 0.5mg
• Bedtime: 0.75mg (reduced from 1mg)
• Total daily dose: 1.25mg 1

Week 3-4: Further reduce bedtime dose

• Morning: 0.5mg
• Bedtime: 0.5mg (reduced from 0.75mg)
• Total daily dose: 1mg 1

Week 5-6: Reduce morning dose

• Morning: 0.25mg (reduced from 0.5mg)
• Bedtime: 0.5mg
• Total daily dose: 0.75mg 1

Week 7-8: Further reduce bedtime dose

• Morning: 0.25mg
• Bedtime: 0.25mg (reduced from 0.5mg)
• Total daily dose: 0.5mg 1

Week 9-10: Reduce to single daily dose

• Morning: 0.25mg
• Bedtime: 0mg (discontinued)
• Total daily dose: 0.25mg 1

Week 11-12: Final discontinuation

• Extend dosing interval to every other day with 0.25mg, then every third day, then discontinue completely 2

Critical Safety Considerations

Abrupt benzodiazepine withdrawal can cause seizures, delirium tremens, hallucinations, and rarely death. 1 The 25% reduction every 1-2 weeks represents a commonly used schedule that has been used safely with moderate success 1, though slower tapers (10% per month) may be better tolerated for patients on long-term therapy 2.

Monitoring Requirements

• Watch for withdrawal symptoms including anxiety, insomnia, tremor, sweating, tachycardia, muscle aches, nausea, and headache 3
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 2, 4
• Clonazepam has a 30-40 hour half-life, so withdrawal symptoms may be delayed 2-3 days after dose reduction 1

Important Caveats for AMA Discharge

Since this patient is leaving against medical advice, provide clear written instructions emphasizing:

• Never abruptly stop or skip doses, as this can cause life-threatening withdrawal including seizures 1
• Do not attempt to restart at the original 1.5mg dose if relapse occurs, as this increases overdose risk 2
• If withdrawal symptoms become intolerable, contact a physician immediately rather than stopping the taper 2
• Avoid alcohol and other CNS depressants during the taper 1

Alternative Slower Taper Option

For patients with history of difficult benzodiazepine withdrawal or prolonged use (>1 year), consider a more conservative approach of reducing by 0.125mg every 2-4 weeks (approximately 10% per month), which would extend the taper to 6 months but may improve tolerability and success rates 2, 3.

The research evidence shows that 68.9% of patients successfully discontinued clonazepam using a 0.25mg per week reduction schedule after the dose reached 1mg/day 3, supporting the feasibility of this approach even in an AMA discharge scenario where follow-up may be limited.