What is the recommended protocol for tapering off Klonopin (clonazepam) in a patient?

How to Taper Off Klonopin (Clonazepam)

Reduce clonazepam by 10-25% of the current dose every 1-2 weeks, with the taper likely requiring a minimum of 6-12 months to minimize withdrawal risks including seizures and death. 1

Critical Safety Warning

Abrupt discontinuation of clonazepam can cause seizures and death—never stop suddenly. 1, 2 This risk is equivalent to suddenly stopping antihypertensives or antihyperglycemics and is never appropriate. 1 Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually. 1

Recommended Tapering Protocol

Initial Assessment Before Starting

• Check your state's Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving 1
• Assess for concurrent substance use disorders, psychiatric comorbidities, and any history of withdrawal seizures 1
• Obtain patient agreement and use shared decision-making, explaining risks of continued use versus benefits of discontinuation 1

Standard Tapering Schedule

Reduce by percentage of current dose, not original dose: 1

• Weeks 1-2: Reduce by 10-25% of the current dose 1
• Weeks 3-4: Reduce by 10-25% of the new current dose 1
• Continue this pattern every 1-2 weeks 1

For example, if starting at 2 mg/day:

• Month 1: Reduce to 1.8 mg/day (10% reduction) 1
• Month 2: Reduce to 1.6 mg/day (10% of 1.8 mg) 1
• Month 3: Reduce to 1.45 mg/day (10% of 1.6 mg) 1

For patients on clonazepam for more than 1 year, extend the taper to 10% per month rather than 10-25% every 1-2 weeks. 1

Alternative Evidence-Based Protocol

A research study demonstrated successful discontinuation using: 3

• Decrease by 0.5 mg per 2-week period until reaching 1 mg/day 3
• Then decrease by 0.25 mg per week 3
• This resulted in 68.9% of patients medication-free after 4 months, with an additional 26% requiring 3 more months 3

Final Dose Strategy

Once the smallest available dose is reached, extend the interval between doses before complete discontinuation. 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

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Monitor

Monitor at least monthly during the taper (more frequently during difficult phases) for: 1

Physical symptoms: 3

• Anxiety, shaking/trembling/tremor
• Nausea/vomiting
• Insomnia/nightmares
• Excessive sweating
• Tachycardia/palpitations
• Headache, weakness, muscle aches

Severe symptoms requiring immediate attention: 2

• Seizures (life-threatening)
• Confusion or altered mental status
• Hallucinations, delirium
• Severe depression or suicidal ideation

If clinically significant withdrawal symptoms occur, further slow the taper rate. 1

Pharmacological Support for Withdrawal

For muscle aches: Consider NSAIDs or acetaminophen 1

For insomnia: Trazodone can be used for short-term management 1

Adjunctive medications with evidence:

• Gabapentin: 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 mitigate withdrawal symptoms, though it may affect alprazolam metabolism 1
• Pregabalin: Has shown potential benefit in facilitating benzodiazepine tapering 1

Non-Pharmacological Support (Essential for Success)

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated. 1 This is one of the most important interventions to improve outcomes. 1

Additional supportive measures: 1

• Mindfulness and relaxation techniques
• Sleep hygiene education
• Exercise and fitness training
• Patient education about benzodiazepine risks and benefits of tapering

Special Situations

If Patient is Taking Both Opioids and Benzodiazepines

Taper the benzodiazepines first due to higher withdrawal risks. 1 The FDA warns that concomitant use increases risk of respiratory depression and death. 2 Keep any buprenorphine or other opioid dose stable during benzodiazepine tapering. 1

Elderly Patients

Use lower doses and more gradual tapers due to increased risks of sedation, cognitive impairment, falls, and fractures. 1 Long-acting agents like diazepam pose particular concerns in this population. 1

Pregnant Patients

Do not taper benzodiazepines during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor. 1

When to Refer to a Specialist Immediately

Refer patients with: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Monitoring Requirements

• Follow up at least monthly during the taper 1
• More frequent contact during difficult phases 1
• Monitor for withdrawal symptoms, depression, anxiety, and substance use disorders 1
• Screen for suicidal ideation—antiepileptic drugs including clonazepam increase risk of suicidal thoughts 2
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost 1

Critical Pitfalls to Avoid

Never taper too quickly. Research shows that even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully. 1

Never abandon the patient. Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy. 1

Do not reduce by fixed amounts. Always reduce by percentage of current dose to prevent disproportionately large final reductions. 1

Do not substitute another benzodiazepine or Z-drug (zolpidem, zaleplon) as these carry similar risks. 1

Realistic Timeline

The taper will likely take 6-12 months minimum, and possibly longer. 1 Tapers may be considered successful as long as the patient is making progress—the goal is durability of the taper, not speed. 1