What is the recommended protocol for weaning a patient off 0.5 mg of Klonopin (clonazepam) twice daily?

Weaning Protocol for Clonazepam 0.5 mg BID

For a patient on clonazepam 0.5 mg BID (1 mg total daily dose), reduce the dose by 0.25 mg per week until complete discontinuation, which should take approximately 4 weeks. 1

Recommended Tapering Schedule

The optimal tapering approach for clonazepam involves weekly reductions of 0.25 mg from the total daily dose. 1 For your patient currently taking 1 mg/day total:

• Week 1-2: Reduce to 0.75 mg/day (0.5 mg + 0.25 mg, or 0.375 mg BID)
• Week 3-4: Reduce to 0.5 mg/day (0.25 mg BID)
• Week 5-6: Reduce to 0.25 mg/day (0.125 mg BID or 0.25 mg once daily)
• Week 7-8: Discontinue completely

This protocol is based on a high-quality study of 73 panic disorder patients who successfully discontinued clonazepam after long-term use (mean dose 2.7 mg/day), where 68.9% were medication-free after 4 months of gradual tapering. 1

Duration-Based Considerations

The tapering speed should be adjusted based on duration of use:

• Less than 7 days: Can discontinue quickly with minimal withdrawal risk 2
• 7-14 days: Reduce by 20% every 24-48 hours 2
• More than 14 days (most outpatients): Use the 0.25 mg per week reduction schedule 1
• Greater than 8 months at high doses: May require slower tapering at 10% of original dose per week 2, 3

Since most outpatients on chronic clonazepam have been taking it for months to years, the weekly 0.25 mg reduction is most appropriate. 1

Monitoring and Management of Withdrawal

Expected withdrawal symptoms are typically mild and include: 1

• Anxiety and restlessness
• Tremor or shaking
• Insomnia or nightmares
• Nausea
• Sweating and palpitations
• Headache and muscle aches

If withdrawal symptoms become problematic: 2

• Maintain the current dose for an additional week before attempting further reduction
• Consider slowing the taper rate to 10% reductions every 1-2 weeks 2, 4
• Use adjunctive medications such as clonidine, gabapentin, or dexmedetomidine to manage symptoms 2

Critical Clinical Considerations

Important caveats to avoid common pitfalls:

• Do not taper multiple sedating medications simultaneously - if the patient is also on opioids or other benzodiazepines, wean one medication at a time to clearly attribute any withdrawal symptoms 2, 4
• Avoid abrupt discontinuation - the FDA label explicitly recommends gradual dose reduction to minimize withdrawal, and treatment should be discontinued gradually with decreases of 0.125 mg BID every 3 days 5
• Monitor for tolerance - clonazepam has a known issue with tolerance development during chronic use, which may complicate the clinical picture 6
• Provide non-pharmacologic support - sleep hygiene education and anxiety management techniques should accompany the taper 2

Alternative Slower Taper for High-Risk Patients

For patients with severe anxiety, prior failed tapers, or very long-term use (>3 years), consider the more conservative FDA-recommended schedule: 5

• Decrease by 0.125 mg BID (0.25 mg total daily) every 3 days
• This results in complete discontinuation in approximately 2-3 weeks for a 1 mg/day dose
• This approach may reduce withdrawal symptom severity in vulnerable patients 5

The key principle is that clonazepam can be successfully discontinued without major withdrawal symptoms if the dose is reduced gradually, with the 0.25 mg per week reduction representing the evidence-based standard for most patients. 1