What is a recommended taper schedule for converting from Ativan (lorazepam) 3 mg to Klonopin (clonazepam)?

Converting from Ativan 3 mg to Klonopin: Recommended Taper Schedule

Convert Ativan (lorazepam) 3 mg to an equivalent dose of Klonopin (clonazepam) 1.5 mg, then initiate a gradual taper reducing by 10-25% of the current dose every 1-2 weeks, with the understanding that benzodiazepine tapering should never be rushed and will likely require 6-12 months minimum. 1

Dose Conversion

• Lorazepam 3 mg is approximately equivalent to clonazepam 1.5 mg based on relative potency data showing lorazepam 2-2.5 mg equals diazepam 10 mg, and clonazepam having higher receptor affinity than diazepam 2, 3
• Clonazepam has a significantly longer duration of action (up to 24-72 hours) compared to lorazepam, which provides more stable blood levels and reduces interdose withdrawal symptoms 4, 5

Initial Conversion Strategy

• Start with a direct switch to clonazepam 1.5 mg daily (can be given as 0.75 mg twice daily or 1.5 mg once daily at bedtime) 4
• Monitor for 1-2 weeks after conversion to ensure stability before beginning taper 1
• The longer half-life of clonazepam (20-80 hours) versus lorazepam makes it inherently easier to taper 5

Tapering Protocol

Week-by-week reduction schedule:

• Weeks 1-2: Clonazepam 1.5 mg daily (stabilization after conversion)
• Weeks 3-4: Reduce to 1.125-1.25 mg daily (25% reduction from current dose) 1
• Weeks 5-6: Reduce to 0.875-1 mg daily (20-25% reduction from current dose) 1
• Weeks 7-8: Reduce to 0.75 mg daily 1
• Continue reducing by 10-25% of the current dose every 1-2 weeks until reaching the lowest available dose 1

Critical modification for long-term users: If the patient has been on benzodiazepines for more than 1 year, extend the taper to 10% reductions per month rather than 10-25% every 1-2 weeks 1

Essential Safety Principles

• Never taper too quickly - abrupt discontinuation can cause seizures and death, making benzodiazepine withdrawal more dangerous than opioid withdrawal 1
• The taper rate must be determined by the patient's tolerance, not a rigid schedule - pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
• Reduce by a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 1
• Once the smallest available dose (0.125-0.25 mg) is reached, extend the interval between doses before complete discontinuation 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 1

Adjunctive Support Strategies

Pharmacological adjuncts:

• Gabapentin can help mitigate withdrawal symptoms: start 100-300 mg at bedtime or three times daily, increase by 100-300 mg every 1-7 days as tolerated 1
• Carbamazepine may help with withdrawal symptoms 1
• Pregabalin has shown potential benefit in facilitating tapering 1
• SSRIs (particularly paroxetine) may manage underlying anxiety during tapering 1
• Trazodone for insomnia during tapering 1

Non-pharmacological interventions (strongly recommended):

• Cognitive behavioral therapy (CBT) during the taper significantly increases success rates 1
• Mindfulness and relaxation techniques 1
• Sleep hygiene education 1
• Exercise and fitness training 1

When to Refer to Specialist

Immediate specialist referral required for:

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders 1
• Previous unsuccessful office-based tapering attempts 1
• Pregnant patients (withdrawal can cause spontaneous abortion and premature labor) 1

Common Pitfalls to Avoid

• Never abandon the patient - even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy 6, 1
• Do not use rigid schedules - research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully 1
• Do not rush the process - tapers are considered successful as long as the patient is making progress; the goal is durability, not speed 1
• Do not reduce doses too aggressively near the end - use percentage-based reductions to avoid disproportionately large final cuts 1

Realistic Expectations

• The taper will likely take 6-12 months minimum, possibly longer 1
• Patient agreement and interest in tapering is a key component of success 1
• Withdrawal symptoms are expected and manageable with proper support 1
• Consider the taper successful as long as progress is being made, even if slower than initially planned 1