What is the best approach to discontinuing Klonopin (clonazepam) in an elderly patient with a 25-year history of use, who is also taking Spravato (esketamine), Lexapro (escitalopram), and Belsomra (suvorexant) for anxiety and depression?

Discontinuing Klonopin in an Elderly Patient on Long-Term Therapy

Direct Recommendation

For this elderly patient with 25 years of Klonopin use, implement a slow hyperbolic taper reducing by 10% of the current dose per month, targeting a minimum 12-month discontinuation timeline, while maintaining stable doses of Spravato, Lexapro, and Belsomra. 1, 2

Critical Safety Framework

Never stop clonazepam abruptly—this can cause seizures and death, making sudden discontinuation as dangerous as abruptly stopping antihypertensives or antihyperglycemics. 3, 2 The 25-year duration of use in this elderly patient places them at extremely high risk for severe withdrawal complications. 3

Why This Patient Requires Extra Caution

• Elderly patients face amplified risks from benzodiazepines including cognitive impairment, falls, fractures, loss of functional independence, and potential dementia with prolonged high-dose use. 3, 1
• The combination with Belsomra (suvorexant, another CNS depressant) increases sedation and respiratory depression risks during any dose changes. 1
• After 25 years of use, neuroadaptation is profound—tolerance loss during tapering means even returning to previous doses could cause overdose. 1

Recommended Tapering Protocol

Month-by-Month Reduction Strategy

Calculate each reduction as 10% of the CURRENT dose, not the original dose—this prevents disproportionately large final reductions that trigger severe withdrawal. 1, 2 For patients on benzodiazepines longer than 1 year (this patient has 25 years), the 10% monthly reduction is safer than faster tapers. 1

Example if starting at 2mg/day clonazepam:

• Month 1: Reduce to 1.8mg/day (10% reduction)
• Month 2: Reduce to 1.62mg/day (10% of 1.8mg)
• Month 3: Reduce to 1.46mg/day (10% of 1.62mg)
• Continue this pattern for 12+ months 1, 2

The taper rate must be determined by the patient's tolerance, not rigid adherence to schedule—pauses are acceptable and often necessary when withdrawal symptoms emerge. 1, 2

Alternative Approach for Very Slow Taper

For the final stages when reaching doses below 0.5mg, consider extending the interval between doses rather than further reducing the amount, as this can ease the final discontinuation. 1 Some patients may require 18-24 months for complete discontinuation. 1

Monitoring Requirements

Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases or dose reductions. 1, 2 At each visit, assess for:

• Withdrawal symptoms: anxiety, tremor, insomnia, sweating, tachycardia, headache, muscle aches, nausea, confusion, and most critically—seizure activity 1, 4
• Mood changes and suicidal ideation 1
• Blood pressure elevation (occurred in 20% of elderly patients in one deprescription study) 5
• Cognitive and psychomotor function (typically improves after successful withdrawal) 6
• Fall risk and functional independence 3, 1

If clinically significant withdrawal symptoms emerge, slow the taper rate further or pause at the current dose until symptoms stabilize. 1

Pharmacological Adjuncts to Ease Withdrawal

First-Line Adjunctive Medication

Gabapentin can mitigate withdrawal symptoms—start with 100-300mg at bedtime or three times daily, increasing by 100-300mg every 1-7 days as tolerated (adjust dose in renal insufficiency). 1, 2 Gabapentin acts on the GABA system without benzodiazepine receptor binding, reducing anxiety, tremor, and insomnia during taper. 1

Alternative Adjunctive Agents

• Carbamazepine may assist discontinuation, though it can affect clonazepam metabolism 1, 6
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering 1
• For persistent anxiety during taper, the patient's existing Lexapro (escitalopram) should be maintained at therapeutic dose; SSRIs help manage underlying anxiety 3, 1

Symptomatic Management

• For insomnia worsening during taper, optimize sleep hygiene education rather than adding another sedative 3, 5
• Trazodone 25-50mg can be used short-term for insomnia without abuse potential 1
• For muscle aches, use acetaminophen or NSAIDs (cautiously in elderly) 1

Non-Pharmacological Interventions (Critical for Success)

Cognitive-behavioral therapy (CBT) during the taper significantly increases success rates and should be incorporated if available. 1, 2, 4 Weekly or biweekly CBT sessions focusing on anxiety management, sleep hygiene, and coping strategies can double discontinuation success rates. 1

Additional supportive measures include:

• Mindfulness and relaxation techniques 1
• Exercise and physical activity programs 1
• Patient education about benzodiazepine risks and withdrawal expectations 1, 5

Managing Concurrent Medications

Keep These Stable During Clonazepam Taper

Maintain stable doses of Spravato (esketamine), Lexapro (escitalopram), and Belsomra (suvorexant) throughout the clonazepam taper—do not adjust multiple CNS-active medications simultaneously. 3, 1 The Lexapro provides foundational treatment for anxiety and depression that will be essential during benzodiazepine withdrawal. 3, 1

Avoid prescribing additional CNS depressants during the tapering period. 1

Special Consideration for Belsomra

Monitor closely for excessive sedation when combining Belsomra with clonazepam, especially as clonazepam doses decrease and the patient may experience rebound insomnia. 1 The Belsomra (suvorexant) works through orexin receptor antagonism, not GABA receptors, so it won't directly address benzodiazepine withdrawal but may help maintain sleep during taper. 3

When to Refer to Specialist

Immediate specialist referral is indicated for: 1, 2

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts
• Patient develops severe withdrawal symptoms despite slow taper

Common Pitfalls to Avoid

Critical Errors That Cause Failure

1. Tapering too quickly: Even a 10% reduction every 3 days resulted in only 24% of patients completing withdrawal successfully 1
2. Calculating reductions from the original dose instead of current dose: This creates disproportionately large final reductions 1, 2
3. Abandoning the patient if tapering is unsuccessful: Maintain the therapeutic relationship and consider maintenance therapy at a lower dose 1
4. Substituting another benzodiazepine or Z-drug (like increasing Belsomra): These carry similar risks in older adults 1
5. Adjusting multiple medications simultaneously: Only taper clonazepam while keeping other medications stable 3, 1

Managing Realistic Expectations

The taper will likely take 12-24 months minimum for this patient with 25 years of use—this is not a failure, it's appropriate caution. 1, 2 Success is defined as durability of the taper, not speed. 1

Patient agreement and interest in tapering is a key component of success—use shared decision-making and explain the risks of continued use versus benefits of discontinuation. 1 For elderly patients, emphasize that successful withdrawal typically results in improved psychomotor and cognitive functioning, particularly in memory and daytime alertness. 1, 6

Expected Withdrawal Symptoms (Mostly Mild if Tapered Properly)

Common withdrawal symptoms during slow taper include: 4

• Anxiety (most common)
• Tremor/shaking
• Insomnia
• Sweating
• Tachycardia/palpitations
• Headache
• Muscle aches
• Nausea

These symptoms are typically mild with the 10% monthly reduction protocol and can be managed with gabapentin, supportive care, and CBT. 1, 2, 4 In one study of clonazepam tapering over 4 months, 68.9% of patients successfully discontinued with only mild symptoms. 4

Outcome Expectations

After successful clonazepam discontinuation, expect: 4, 6

• Improved psychomotor and cognitive functioning
• Better memory and daytime alertness
• Maintained improvement in anxiety symptoms (the underlying anxiety disorder is being treated with Lexapro and Spravato)
• Reduced fall risk and improved functional independence 3, 1

The patient's depression and anxiety should remain controlled with the combination of Spravato (esketamine) and Lexapro (escitalopram), which are addressing the underlying psychiatric conditions independent of the benzodiazepine. 3