What is the cross-taper schedule from clonazepam (Benzodiazepine) 0.25mg twice a day (BID) to an equivalent dose of diazepam (Benzodiazepine)?

Cross-Taper from Clonazepam 0.25mg BID to Diazepam

Convert clonazepam 0.25mg BID (total 0.5mg daily) to diazepam 5mg BID (total 10mg daily) using a 1:10 equivalency ratio, then taper the diazepam gradually over weeks to months at a rate of approximately 10% per week or slower depending on withdrawal symptoms. 1

Dose Equivalency Conversion

• Clonazepam 0.5mg daily (0.25mg BID) is approximately equivalent to diazepam 10mg daily (5mg BID) using the standard benzodiazepine equivalency ratio of 1:10 for clonazepam to diazepam 2, 3
• This is a relatively low dose of benzodiazepine (mean daily diazepam equivalents in psychiatric populations is approximately 25mg) 2

Cross-Taper Strategy

Direct substitution is preferred over gradual cross-taper at this low dose:

• Day 1: Discontinue clonazepam 0.25mg BID and start diazepam 5mg BID 3
• Diazepam's longer half-life (20-100 hours including active metabolites) provides smoother coverage compared to clonazepam's intermediate duration (24 hours), making abrupt substitution safer at therapeutic doses 3
• The longer duration of action of diazepam (via its active metabolite N-desmethyldiazepam) reduces the risk of interdose withdrawal symptoms 3, 4

Subsequent Diazepam Taper Schedule

After stabilization on diazepam 10mg daily for 1-2 weeks, begin gradual taper:

• Week 1-2: Diazepam 5mg BID (10mg total daily) - stabilization phase
• Week 3-4: Reduce to 4mg BID (8mg daily) - 20% reduction 1
• Week 5-6: Reduce to 3mg BID (6mg daily) - 25% reduction of current dose
• Week 7-8: Reduce to 2.5mg BID (5mg daily) - approximately 17% reduction
• Week 9-10: Reduce to 2mg BID (4mg daily) - 20% reduction
• Continue reducing by 0.5-1mg every 1-2 weeks until discontinuation 1

The Mayo Clinic Proceedings guideline recommends initial reductions of 10% per week as a starting point, with slower tapers (10% per month or slower) being more appropriate for patients on prolonged benzodiazepine therapy 1. Given this is a low dose, a slightly faster taper of 10-20% every 1-2 weeks is reasonable 1.

Adjunctive Medications for Withdrawal Management

Consider adding medications to mitigate withdrawal symptoms:

• Clonidine 0.1mg BID or TID - directly attenuates benzodiazepine withdrawal symptoms but monitor for orthostasis/hypotension 1
• Tizanidine 2mg TID - alternative α2-agonist with less hypotensive effect than clonidine 1
• Gabapentin 300-900mg daily in divided doses - helps with anxiety and insomnia during taper 1
• Trazodone 25-50mg at bedtime - for insomnia without benzodiazepine receptor activity 1

Critical Safety Considerations

• Monitor for withdrawal symptoms including anxiety, insomnia, irritability, tremor, and in severe cases, seizures 1, 5
• Avoid abrupt discontinuation as this can precipitate severe withdrawal including seizures, even at low doses 5
• Respiratory depression risk increases significantly if combined with opioids - reduce doses of both agents by at least 20% if concurrent use is necessary 6, 5
• Elderly patients may require slower taper rates (reduce by 50% or more initially) due to increased sensitivity 5
• Protracted withdrawal symptoms (dysphoria, insomnia, anhedonia) may persist for months after complete discontinuation and should be anticipated and discussed with the patient 1

Monitoring During Taper

• Assess withdrawal symptoms at each dose reduction using standardized scales if available 1
• If significant withdrawal symptoms emerge, hold at current dose for 1-2 additional weeks before proceeding 1
• If severe withdrawal occurs, increase back to previous tolerated dose and slow the taper rate 1
• Provide adequate clinician time and support throughout the taper process, as this improves success rates 1