Switching from Lorazepam 3mg Daily to Clonazepam
Convert lorazepam 3mg daily to clonazepam 1.5mg daily using a direct switch, then taper the clonazepam gradually by 0.25mg per week once the patient is stable.
Conversion and Initial Switch
Lorazepam 3mg daily is approximately equivalent to clonazepam 1.5mg daily based on benzodiazepine equivalency dosing, where lorazepam 1mg equals clonazepam 0.5mg 1.
A direct switch is generally safe and well-tolerated between benzodiazepines when neither agent is a monoamine oxidase inhibitor or tricyclic antidepressant, avoiding compliance issues associated with complex tapering schedules 2.
Start clonazepam at 1.5mg daily, divided into two or three doses (e.g., 0.5mg three times daily or 0.75mg twice daily), as clonazepam has a long elimination half-life of 30-40 hours allowing for flexible dosing 3.
Stabilization Period
Allow 1-2 weeks for stabilization on clonazepam before initiating any taper, as clonazepam reaches steady-state concentrations within this timeframe given its pharmacokinetic profile 4.
Monitor for withdrawal symptoms during this transition including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion 1.
The longer half-life of clonazepam (30-40 hours) compared to lorazepam (12-18 hours) provides more stable plasma levels and reduces rebound anxiety between doses 3, 4.
Tapering Schedule Once Stable
If the goal is to discontinue benzodiazepines entirely:
Reduce clonazepam by 0.25mg per week after the patient has been stable on the converted dose, as this gradual approach minimizes withdrawal symptoms and has been validated in clinical studies 5.
The reduction should be by percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 1.
A sample schedule from clonazepam 1.5mg daily would be:
- Weeks 1-2: Stabilization at 1.5mg daily
- Week 3: Reduce to 1.25mg daily
- Week 4: Reduce to 1.0mg daily
- Week 5: Reduce to 0.75mg daily
- Week 6: Reduce to 0.5mg daily
- Week 7: Reduce to 0.25mg daily
- Week 8: Discontinue 5
For patients on benzodiazepines for more than 1 year, consider extending the taper to 10% per month rather than weekly reductions, as this slower approach improves success rates 1.
Critical Safety Considerations
Abrupt discontinuation of benzodiazepines can cause seizures and death and should never be attempted 1.
The taper rate must be determined by the patient's tolerance, not a rigid schedule, and pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1.
Follow up at least monthly during the taper, with more frequent contact during difficult phases 1.
Integrating cognitive behavioral therapy (CBT) during the taper significantly increases success rates and should be offered alongside pharmacological management 1.
Common Pitfalls to Avoid
Do not taper too quickly - research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully 1.
Clonazepam discontinuation symptoms are mostly mild but can include anxiety, tremor, nausea, insomnia, excessive sweating, tachycardia, headache, weakness, and muscle aches 5.
If withdrawal symptoms emerge, slow the taper or pause temporarily rather than abandoning the patient or returning to higher doses 1.
Monitor for depression, anxiety, and suicidal ideation throughout the tapering process 1.
When to Refer to a Specialist
Patients with history of withdrawal seizures should be referred immediately rather than managed in primary care 1.
Patients with unstable psychiatric comorbidities, co-occurring substance use disorders, or previous unsuccessful tapering attempts require specialist involvement 1.
Pregnant patients should not taper benzodiazepines without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 1.