What is the recommended tapering schedule for clonazepam (Klonopin)?

Clonazepam Tapering Protocol

For clonazepam discontinuation, reduce the dose by 0.25 mg per week after reaching 1 mg/day, with slower reductions of 0.5 mg every 2 weeks for higher doses, extending the taper over several months to minimize withdrawal symptoms and seizure risk. 1

Recommended Tapering Schedule

For Doses Above 1 mg/day

• Reduce by 0.5 mg every 2 weeks until reaching 1 mg/day 1
• This initial phase addresses higher doses where larger reductions are better tolerated 1

For Doses at or Below 1 mg/day

• Reduce by 0.25 mg per week once at 1 mg/day or below 1
• These smaller, more frequent reductions become critical as the total dose decreases to prevent disproportionately large drops in receptor occupancy 2

Alternative Slower Approach for Long-Term Users

• For patients on clonazepam for more than 1 year, consider 10% reductions of the current dose per month rather than fixed-dose decrements 2
• Each reduction should be 10% of the most recent dose, not the original dose, to maintain proportional decreases 2
• This hyperbolic tapering approach may better accommodate neuroadaptations that persist for months after benzodiazepine exposure 3

Expected Timeline and Success Rates

• 68.9% of patients successfully discontinued clonazepam within 4 months using the 0.5 mg/2-week then 0.25 mg/week protocol 1
• An additional 26% required up to 3 more months (total 7 months) to complete discontinuation 1
• The mean starting dose in this successful cohort was 2.7 mg/day 1

Managing Withdrawal Symptoms

Common Withdrawal Symptoms (Mostly Mild)

• Anxiety, tremor/shaking, nausea/vomiting 1
• Insomnia/nightmares, excessive sweating 1
• Tachycardia/palpitations, headache 1
• Weakness and muscle aches 1

Adjunctive Strategies

• Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates 2
• Consider gabapentin (starting 100-300 mg at bedtime or three times daily, titrating by 100-300 mg every 1-7 days) to mitigate withdrawal symptoms 2
• Carbamazepine or pregabalin may help manage withdrawal symptoms, though carbamazepine can affect alprazolam metabolism 2

If Withdrawal Symptoms Become Severe

• Return to the previous dose temporarily 4
• Resume tapering at a slower rate (consider 5% monthly reductions) 4
• Increase monitoring frequency beyond monthly visits during difficult phases 2

Critical Safety Warnings

Seizure Risk

• Abrupt discontinuation can cause seizures and death 2, 5
• Even "gradual" tapers of 0.5 mg every 4 days have resulted in seizures 6
• The 0.25 mg per week reduction is safer than faster schedules 1, 6

Monitoring Requirements

• Follow up at least monthly during tapering 2
• More frequent contact may be needed during difficult phases 2
• Monitor for withdrawal symptoms, mood changes, and suicidal ideation 2
• Screen for depression, anxiety, and substance use disorders that may emerge 2

Special Populations

Elderly Patients

• Start with lower doses and observe closely 5
• Consider more gradual tapers with smaller dose reductions 2
• Be aware of increased risk for confusion, falls, and potential subdural hematoma at doses of 2 mg nightly 7

Patients with Comorbidities

• If taking both opioids and benzodiazepines, taper the benzodiazepine first due to higher withdrawal risks 2
• Patients with history of withdrawal seizures should be referred to a specialist 2
• Those with unstable psychiatric comorbidities require specialist involvement 2

Common Pitfalls to Avoid

• Do not use fixed-dose reductions throughout the entire taper - switch to percentage-based reductions as dose decreases 2
• Do not taper faster than 0.25 mg per week below 1 mg/day - this increases seizure risk 1, 6
• Do not abruptly stop even at very low doses - final doses before complete cessation may need to be as small as 1/40th of a therapeutic dose 3
• Do not ignore the need for pauses - pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 2
• Warn patients about increased overdose risk if they return to previous doses after tolerance is lost 2

Practical Implementation

• The taper rate must be determined by the patient's tolerance, not a rigid schedule 2
• Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement 2
• Incorporate psychological support including mindfulness, relaxation techniques, and psychotherapy 2
• For sleep issues during tapering, prioritize sleep hygiene education over substituting another medication 2