How to taper off Klonopin (clonazepam) 0.5mg by switching to Valium (diazepam) 10mg?

Benzodiazepine Cross-Taper: Clonazepam to Diazepam

For a patient on clonazepam 0.5 mg daily, switch to diazepam 10 mg daily (using a 1:20 conversion ratio), then taper the diazepam by 10-25% of the current dose every 1-2 weeks, extending over several months given the long-term nature of benzodiazepine use. 1

Why Switch to Diazepam?

Diazepam is preferred for benzodiazepine tapering because it is available in liquid formulation, allowing for more precise dose reductions, and has a longer half-life that smooths withdrawal symptoms. 2 The conversion from clonazepam 0.5 mg to diazepam 10 mg represents an equipotent dose using standard benzodiazepine equivalency tables.

Step-by-Step Tapering Protocol

Initial Conversion

• Day 1: Switch directly from clonazepam 0.5 mg to diazepam 10 mg daily 3
• No overlap period is needed; make a direct substitution
• Monitor for 1-2 weeks to ensure stability on the new medication before beginning taper 1

Tapering Schedule

Weeks 1-2: Reduce to diazepam 7.5 mg daily (25% reduction from 10 mg) 1, 4

Weeks 3-4: Reduce to diazepam 5-6 mg daily (20-25% of current dose) 1

Weeks 5-6: Reduce to diazepam 4-4.5 mg daily (20-25% of current dose) 1

Weeks 7-8: Reduce to diazepam 3 mg daily 1

Weeks 9-10: Reduce to diazepam 2 mg daily 1

Weeks 11-12: Reduce to diazepam 1 mg daily 1

Weeks 13-14: Reduce to diazepam 0.5 mg daily 1

Week 15+: Discontinue completely 1

Critical Tapering Principles

• Reduce by percentage of CURRENT dose, not original dose - this prevents disproportionately large reductions at the end of the taper 1
• For patients on benzodiazepines for >1 year, consider extending the taper to 10% per month rather than 10-25% every 1-2 weeks 5, 1
• The taper rate must be determined by the patient's tolerance, not a rigid schedule 1
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 5, 1

Managing Withdrawal Symptoms

Expected Withdrawal Symptoms

• Anxiety, insomnia, muscle tension and spasms 6
• Perceptual hypersensitivity, irritability, restlessness 6
• Gastrointestinal symptoms (nausea, decreased appetite) 6
• Headache, dizziness, fatigue 6

Severe Withdrawal Warning Signs

• Seizures are the most dangerous complication - they can occur even with therapeutic doses if discontinued abruptly 7
• Confusion, hallucinations, severe agitation require immediate medical attention 6
• If severe withdrawal symptoms develop, pause the taper or increase back to the previous dose 3

Adjunctive Medications to Consider

• Gabapentin: Start 100-300 mg at bedtime or three times daily, increase by 100-300 mg every 1-7 days as tolerated to help mitigate withdrawal symptoms 1
• Pregabalin: Has shown benefit in facilitating benzodiazepine tapering 1, 4
• Carbamazepine: Can help mitigate withdrawal symptoms, though evidence is limited 1, 4
• SSRIs (e.g., paroxetine): May manage underlying anxiety during tapering 1

Non-Pharmacological Support

• Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be strongly considered 1
• Patient education about benzodiazepine risks and benefits of tapering improves engagement 1
• Incorporate mindfulness, relaxation techniques, and supportive psychotherapy 1

Monitoring Requirements

• Follow up at least monthly during the taper 5
• More frequent contact (weekly or biweekly) may be needed during difficult phases 5
• Monitor for withdrawal symptoms, mood changes, and suicidal ideation 5
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 5

Critical Pitfalls to Avoid

• Never discontinue benzodiazepines abruptly - this can cause seizures and death 1, 6, 7
• Avoid concurrent use of other CNS depressants (opioids, alcohol) during the taper 4
• If patient is also on opioids, taper the benzodiazepine FIRST due to higher withdrawal risks 1
• Do not substitute another sedative-hypnotic during the taper - this risks creating a new dependence 1

When to Refer to a Specialist

• History of withdrawal seizures 1, 4
• Co-occurring substance use disorders 1, 4
• Unstable psychiatric comorbidities 1
• Previous failed taper attempts in primary care 1
• High-dose benzodiazepine use (>diazepam 40 mg equivalent daily) 8

Special Considerations

• For elderly patients: Use a more gradual taper with smaller dose reductions 1
• For patients on benzodiazepines >6 years: Expect the taper to take several months 4
• Renal insufficiency: Adjust gabapentin dosing if used as adjunctive therapy 1
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 5, 6