Tapering Rivotril Liquid / Clonazepam

Hello to all,

I am from Germany and need a little help with my reduction of Rivotril / Clonazepam.

It started in 2019 with a burnout and a huge anxiety. Previously I was taking Cipro and was floxed. Escitalopram only made it worse and I developed akathisia. In the clinic I was given 3 x 0.5 mg Lorazepam / Ativan. Back from the clinic, my doctor changed this to 3x 0.4 mg Clonazepam.

In Germany we get the drug in a liquid solution. Rivotril drops 1ml = 2.5 mg; 1 drop = 0.1 mg.

Recently my doctor increased the dose from 3 x 0.4 mg to 3x 0.5 mg to stabilize me before I start the reduction. This has worked.

I plan to reduce by 5% a month starting Sept 01. I dissolve the 5 drops (per dose) in 50 ml of water and shake the solution and take away 0.1 ml per dose every day. Thus I come approximately on 5 % in the month. In total this would mean: 15 drops in 150 ml and remove 0.3 ml everday (0,3; 0,6; 0,9). But I can do this per dose, since we have the drops.

Do you think that 5% is too little? I have tried this before and it was quite rough. But at that time I removed 10% per month, starting from the last dose.

The drops consist of the medication and the carrier is propylene glycol. From my research PG dissolves very well in water. I hope I can get a consistent solution by shaking it. Is there any experience on this?

My doctor says I should not reduce completely, but just get to a reasonable amount, which for Him would be 3 x 0.3 mg. I felt okay with that at the time.

Thank you in advance for the help and I hope I will manage to reduce in this way.

What I forgot:

In Germany, the equivalence is converted differently. 2.0 mg clonazepam is equivalent to 10 mg Valium. I have done several searches on this and every site says something different.

You can read about it here:

https://de.wikipedia.org/wiki/Liste_von_Benzodiazepinen

Or here:

https://www.praxis-suchtmedizin.ch/praxis-suchtmedizin/index.php/de/medikamente/benzodiabepine/aequivalenztabelle-bdz

Outside Europe rather with 0.5 = 10 mg. A bit confusing. My doctor said that the potency for epilepsy is about 0.5 = 10 mg but for anxiety about 1 - 2 mg = 10 mg Valium.

Maybe that is more the case if you convert with 1 mg = 10 mg Valium.

Guten Tag, Srilanga!

Given your medication history and negative experience with a 10% reduction, trying a 5% per month taper rate sounds sensible to me. Generally speaking, it’s far easier to speed up a ‘too slow’ taper than it it to slow down and recover from one that is too fast. 

Speaking of taper rates … if you are not already planning to do so, might I encourage you to keep a taper journal to track your withdrawal symptoms and functionality on a daily basis? Reviewing the data in your journal on a regular basis will allow you to make informed decisions about adjusting your taper rate.

Re: your question about diluting the Rivotril oral solution …

We have multiple members who have used/are using the Rivotril oral solution in a manner similar to the one you have described.  To my knowledge, none of them has reported issues.

However, I would be remiss if I did not let you know that there are more unknowns than knowns regarding do-it-yourself (DIY) liquids.  For example, we do not know what happens to the Active Pharmaceutical Ingredient (API) in the oral clonazepam solution when more water is added (e.g. it’s possible some of the API may precipitate out of solution; it’s also possible that the resulting change in pH might have an impact).

Consequently, I suggest you regard your do-it-yourself (DIY) liquid as a ‘suspension with unknown stability.’  Happily, the plan you’ve outlined already includes ‘best practices’ for using such DIY liquids (e.g. make smaller rather than larger batches, shake the liquid well before using it, measure reductions/doses as quickly as possible before any precipitate falls out of suspension).

Re: your second post about the benzodiazepine equivalents used in your country differing from those in other countries …

I’m not surprised.  Per the ‘About this Calculator’ section of the Benzodiazepine Equivalents Calculator (see link below), most benzodiazepine equivalence estimates are based on expert opinion, uncited tables in published documents, and clinical practice.  Moreover, most of the evidence that is available comes from an alcohol withdrawal setting.  Consequently, many benzodiazepine equivalence estimates have a wide range of values.

Link:

Benzodiazepine Equivalents Calculator - ClinCalc.com

https://clincalc.com/Benzodiazepine/

Hello,

thank you Libertas for your very detailed information. It has helped me a lot.

Since you are not allowed to give the oral Rivotril solution into the mouth anyway (it says so in the package insert), I have dissolved it in water beforehand anyway. So reducing it will not change anything. If something did not fit before, it is then equivalent, so to speak. The package insert suggests dissolving them in tea or water before taking a dose.

They encouraged me to keep a diary and I created a very meticulous excel spreadsheet for my taper that calculates everything on its own as soon as I enter a percentage. It always calculates it from the last reduction, so it would take almost 2 1/2 years. That seemed long to me. But I'd also rather go slow and eventually pick up speed than the other way around. That was a very good hint.

On equivalencies: Also a very good addiction clinic and addiction doctor in our area calculates clonazepam between 1 - 2 mg = 10 mg. He bases it on the fact that it is less antianxiety but all the more potent in epilepsy prevention.

Maybe this will help:

https://catbull.com/alamut/Lexikon/Indexe/Wirkprofile_Benzodiazepine.gif

The red bar is the anti-anxiety effect and that's where clonazepam really loses.

Kind regards from Germany!

You are most welcome, Srilanga.

You are correct that the instructions for using the Rivotril oral solution indicate the drops should not be administered directly into the mouth from the bottle (my guess is this is to avoid contamination of the dropper).  However, measuring the entire dose of Rivotril using the dropper and mixing it with another liquid prior to ingestion is not the same as the application you have proposed (i.e. measuring an excess amount of the Rivotril solution using the dropper, adding the drops to a specific volume of water, and then measuring your dose/reduction from the diluted Rivotril/water mixture). 

In the first application, individuals can be reasonably confident of dosing accuracy because they are measuring and ingesting a known amount of a professionally formulated and manufactured oral solution with known properties .  In the second application, dosing accuracy is unknown because the properties of the modified diluted Rivotril/water mixture being used as the ‘drug source’ are unknown.

Happily, researchers at The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin recently received funding to investigate whether such do-it-yourself (DIY) approaches to titration allow for safe and accurate dosing. To learn more about this research project, read the first post in the thread linked below.

Link:

SAFEGUARDING Psychotropic Use Project:

Supporting Safe and Gradual Reduction of Long-Term Psychotropic Use.

http://www.benzobuddies.org/forum/index.php?topic=269263.msg3383270#msg3383270