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Please help with liquid taper


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Hello,

 

I am currently on .45 mg klonopin/day.

My psychiatrist is absolutely useless, so posting here for help with a liquid taper.

 

I am looking to reduce daily, obviously using a small percentage each today.

My issue is I have horrendous tinnitus, caused by starting klonopin in January. I had preexisting tinnitus but it was extremely mild.

 

I don't even know where to begin. I was doing 10% each 10-14 days, but each time I jump down I have even worse tinnitus for multiple days in a row. It is too distressing this way and I would rather taper each day, and hold when needed.

 

Can someone please advise?

I am looking for info on how to do this with 1 mg tablets, as well as .5 mg tablets which I plan to move to soon.

I would ideally like to split the doses up into 2 times per day.

 

***I would like to reduce 1% per day***

 

Example, by days.

0.45

0.4455

0.441045

0.43663455

0.432268205

0.427945522

0.423666067

 

 

Thanks

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I am also fine with a dry taper, reducing every day, following my c/p of my excel ss, but my jewelers scale is not very accurate, even though it goes to .001. It can vary +- .005 very easily.

 

So if anyone has a good jewelers scale, that might also work.

 

Thanks!

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Would your psychiatrist be willing to prescribe a compounded oral clonazepam suspension and/or the orally disintegrating tablets (ODTs)?

 

 

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Would your psychiatrist be willing to prescribe a compounded oral clonazepam suspension and/or the orally disintegrating tablets (ODTs)?

 

He said it wasn't available, pertaining to the compounded oral clonazepam suspension.

I have never heard of ODT's.

 

I guess I am just trying to figure out the best way to make daily reductions.

Maybe I just need a more accurate jewelers scale.

 

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The oral suspension can be made any compounding pharmacy that has the necessary expertise, equipment, and ingredients.  I wonder if your psychiatrist does not know how to write a prescription for a compound and doesn’t want to admit this to you?  If so, one option to consider would be to find a suitably qualified compounding pharmacist — s/he can tell you exactly how the Rx needs to be written.  Then you can give this information to your psychiatrist.

 

I’ve included a link to the stability-tested formulation for a 0.1mg/mL oral clonazepam suspension below.  We also have members who make their own do-it-yourself (DIY) suspensions using this formulation.  The suspending vehicle used (OraBlend or OraPlus) can be purchased from Amazon.  If OraPlus/Blend is not available, there are other commercial suspending vehicles (e.g. SyrSpend from Faragon, FlavorBlend from Humco).

 

I asked about the clonazepam Orally Disintegrating Tablets (ODTs) because they are available in lower strengths (i.e. 0.125mg and 0.25mg). We have members who dry cut the ODTs as well as members who have used them to make a DIY liquid.  I’ve included links to the official FDA Drug Labels for two of the ODT manufacturers (Teva and Sun) below.

 

In addition to the lower strength, another plus of the ODTs is that they can be used in combination with a liquid to taper. For example:

 

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

 

Modifying/manipulating a dosage form (e.g. making a DIY liquid using a tablet or weighing tablet pieces or powder) conveys risk.  Consequently, it’s preferable to keep as much of the dose in unmodified form as long as possible.

 

Links:

0.1mg/mL Clonazepam Oral Suspension from Nationwide Children’s Hospital

https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/clonazepam-oral.ashx

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Teva

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cb2e209e-e69b-422b-8abb-34df2bc92caa

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Sun

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=62d0ed23-3452-4a12-ae9e-bbb8d8a0f8e7

 

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As Libertas suggested liquid compound is the ideal way to do a slow and precise taper. If you live in a city there should be a compound pharmacy somewhere. You probably have to do the job to find one. Call them and ask if they can compound clonazepam.   
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The oral suspension can be made any compounding pharmacy that has the necessary expertise, equipment, and ingredients.  I wonder if your psychiatrist does not know how to write a prescription for a compound and doesn’t want to admit this to you?  If so, one option to consider would be to find a suitably qualified compounding pharmacist — s/he can tell you exactly how the Rx needs to be written.  Then you can give this information to your psychiatrist.

 

I’ve included a link to the stability-tested formulation for a 0.1mg/mL oral clonazepam suspension below.  We also have members who make their own do-it-yourself (DIY) suspensions using this formulation.  The suspending vehicle used (OraBlend or OraPlus) can be purchased from Amazon.  If OraPlus/Blend is not available, there are other commercial suspending vehicles (e.g. SyrSpend from Faragon, FlavorBlend from Humco).

 

I asked about the clonazepam Orally Disintegrating Tablets (ODTs) because they are available in lower strengths (i.e. 0.125mg and 0.25mg). We have members who dry cut the ODTs as well as members who have used them to make a DIY liquid.  I’ve included links to the official FDA Drug Labels for two of the ODT manufacturers (Teva and Sun) below.

 

In addition to the lower strength, another plus of the ODTs is that they can be used in combination with a liquid to taper. For example:

 

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

 

Modifying/manipulating a dosage form (e.g. making a DIY liquid using a tablet or weighing tablet pieces or powder) conveys risk.  Consequently, it’s preferable to keep as much of the dose in unmodified form as long as possible.

 

Links:

0.1mg/mL Clonazepam Oral Suspension from Nationwide Children’s Hospital

https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/clonazepam-oral.ashx

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Teva

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cb2e209e-e69b-422b-8abb-34df2bc92caa

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Sun

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=62d0ed23-3452-4a12-ae9e-bbb8d8a0f8e7

 

I feel like for my situation the liquid taper is best, because the 1 mg pills I get range from .167g to .174g, making it not super accurate. Combined with my not amazing .001 scale, I fear I am not getting dosages right. I seem to be very sensitive to this medication from my past history.

 

I live in a city of 3 million people, my psych must be clueless.

 

I just feel extremely overwhelmed, I don't know what to do if I was able to get the liquid anyways.

Should I just report back if I am able to get the liquid?

 

I'm sorry for my naivety, the screaming in my head mixed with this withdrawal is hell.

 

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The oral suspension can be made any compounding pharmacy that has the necessary expertise, equipment, and ingredients.  I wonder if your psychiatrist does not know how to write a prescription for a compound and doesn’t want to admit this to you?  If so, one option to consider would be to find a suitably qualified compounding pharmacist — s/he can tell you exactly how the Rx needs to be written.  Then you can give this information to your psychiatrist.

 

I’ve included a link to the stability-tested formulation for a 0.1mg/mL oral clonazepam suspension below.  We also have members who make their own do-it-yourself (DIY) suspensions using this formulation.  The suspending vehicle used (OraBlend or OraPlus) can be purchased from Amazon.  If OraPlus/Blend is not available, there are other commercial suspending vehicles (e.g. SyrSpend from Faragon, FlavorBlend from Humco).

 

I asked about the clonazepam Orally Disintegrating Tablets (ODTs) because they are available in lower strengths (i.e. 0.125mg and 0.25mg). We have members who dry cut the ODTs as well as members who have used them to make a DIY liquid.  I’ve included links to the official FDA Drug Labels for two of the ODT manufacturers (Teva and Sun) below.

 

In addition to the lower strength, another plus of the ODTs is that they can be used in combination with a liquid to taper. For example:

 

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

 

Modifying/manipulating a dosage form (e.g. making a DIY liquid using a tablet or weighing tablet pieces or powder) conveys risk.  Consequently, it’s preferable to keep as much of the dose in unmodified form as long as possible.

 

Links:

0.1mg/mL Clonazepam Oral Suspension from Nationwide Children’s Hospital

https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/clonazepam-oral.ashx

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Teva

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cb2e209e-e69b-422b-8abb-34df2bc92caa

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Sun

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=62d0ed23-3452-4a12-ae9e-bbb8d8a0f8e7

 

So my plan is to call a pharmacy and see if they can compound klonopin into .1mg/ml, I will do that on Monday when they open.

I will then get with my psychiatrist and get him to write a script for that.

 

Could you please help me with what to do with that .1 mg/ml solution?

If you could explain this like I'm 5 that would be fantastic. I'm sorry be such a bother.

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The oral suspension can be made any compounding pharmacy that has the necessary expertise, equipment, and ingredients.  I wonder if your psychiatrist does not know how to write a prescription for a compound and doesn’t want to admit this to you?  If so, one option to consider would be to find a suitably qualified compounding pharmacist — s/he can tell you exactly how the Rx needs to be written.  Then you can give this information to your psychiatrist.

 

I’ve included a link to the stability-tested formulation for a 0.1mg/mL oral clonazepam suspension below.  We also have members who make their own do-it-yourself (DIY) suspensions using this formulation.  The suspending vehicle used (OraBlend or OraPlus) can be purchased from Amazon.  If OraPlus/Blend is not available, there are other commercial suspending vehicles (e.g. SyrSpend from Faragon, FlavorBlend from Humco).

 

I asked about the clonazepam Orally Disintegrating Tablets (ODTs) because they are available in lower strengths (i.e. 0.125mg and 0.25mg). We have members who dry cut the ODTs as well as members who have used them to make a DIY liquid.  I’ve included links to the official FDA Drug Labels for two of the ODT manufacturers (Teva and Sun) below.

 

In addition to the lower strength, another plus of the ODTs is that they can be used in combination with a liquid to taper. For example:

 

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

0.125mg ODT + 0.125mg in liquid (taper the liquid to 0)

 

Modifying/manipulating a dosage form (e.g. making a DIY liquid using a tablet or weighing tablet pieces or powder) conveys risk.  Consequently, it’s preferable to keep as much of the dose in unmodified form as long as possible.

 

Links:

0.1mg/mL Clonazepam Oral Suspension from Nationwide Children’s Hospital

https://www.nationwidechildrens.org/-/media/nch/specialties/pharmacy/compounding-formulas/clonazepam-oral.ashx

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Teva

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cb2e209e-e69b-422b-8abb-34df2bc92caa

 

DailyMed - CLONAZEPAM tablet, orally disintegrating - Sun

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=62d0ed23-3452-4a12-ae9e-bbb8d8a0f8e7

 

So my plan is to call a pharmacy and see if they can compound klonopin into .1mg/ml, I will do that on Monday when they open.

I will then get with my psychiatrist and get him to write a script for that.

 

Could you please help me with what to do with that .1 mg/ml solution?

If you could explain this like I'm 5 that would be fantastic. I'm sorry be such a bother.

 

I understand I would do 4.5 ml to equal .45mg, but when it gets down to the smaller doses, like my next at .445 mg, I'm not sure how I would accurately measure 4.45 ml with a syringe.

 

Hope that makes sense and thank you again.

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-Remember, has to be a compound Pharmacy. You can go to your regular Pharmacy and ask them where there is one in the city.

-The ideal ratio of the suspension should be 0.1 mg / ml. So for 50 ml it would be 10 x 0.5 mg pills and 50 ml of suspension media ( 10x0.5/50= 0.1mg/ml).

This would fit in a 50ml bottle. Be aware that if you are going full liquid with all your doses you are going to need a larger suspension probably 100ml.

-Not really necessary BUT it would be ideal that the compound pharmacy use the same manufacturer of the drug that you've been taking so far. If not

possible I wouldn't switch to all liquid on the get go. Probably hold for a while starting the liquid with one of the doses and fraction the pills accordingly

with the rest of the doses. Although no precise I use 1/2 of 0.5mg pill that is scored but I would even cut the half in 1/4's if taking the same day.

-You can buy 100ml syringes at amazon without needles. They go by 2's marks between decimals. The 10 divisions are hard to find. The 2's division are spaced enough to do the cut in my opinion.

-Your numbers look close to mine. I'm holding at 0.350 mg. I hit the wall after dropping 0.400mg in 3+ months. Last cuts were too much. So be careful.

 

 

 

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-Remember, has to be a compound Pharmacy. You can go to your regular Pharmacy and ask them where there is one in the city.

-The ideal ratio of the suspension should be 0.1 mg / ml. So for 50 ml it would be 10 x 0.5 mg pills and 50 ml of suspension media ( 10x0.5/50= 0.1mg/ml).

This would fit in a 50ml bottle. Be aware that if you are going full liquid with all your doses you are going to need a larger suspension probably 100ml.

-Not really necessary BUT it would be ideal that the compound pharmacy use the same manufacturer of the drug that you've been taking so far. If not

possible I wouldn't switch to all liquid on the get go. Probably hold for a while starting the liquid with one of the doses and fraction the pills accordingly

with the rest of the doses. Although no precise I use 1/2 of 0.5mg pill that is scored but I would even cut the half in 1/4's if taking the same day.

-You can buy 100ml syringes at amazon without needles. They go by 2's marks between decimals. The 10 divisions are hard to find. The 2's division are spaced enough to do the cut in my opinion.

-Your numbers look close to mine. I'm holding at 0.350 mg. I hit the wall after dropping 0.400mg in 3+ months. Last cuts were too much. So be careful.

 

Thanks,

 

Yes I understand I would have to go to a compound pharmacy, and thanks for the heads up about the same manufacturer.

 

I am confused why you suggested a 100 ml syringe with 2's marks between the decimals. Since I would be measuring 4.45 ml, wouldn't it be best to find a 10 ml syringe with smaller marks in between?

 

https://www.amazon.com/Industrial-Scientific-Measuring-Filtration-Choice%EF%BC%9A150ML/dp/B08JPKFFBP/ref=asc_df_B08JPKFFBP/?tag=hyprod-20&linkCode=df0&hvadid=509606954327&hvpos=&hvnetw=g&hvrand=7307352668465106853&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9028708&hvtargid=pla-1269432906647&psc=1

 

Using the one pictured above, I don't think I would be able to measure out 4.45 ml, unless I'm doing math wrong.

 

Thanks,

Dana

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micedana:  Good to see you on the boards as always! Thank you for sharing the lessons you have learned about finding and working with a compounding pharmacy as well as making and using your own do-it-yourself (DIY) suspension.  Did you mean to write ‘You can buy 1mL syringes’ instead of ‘You can buy 100mL syringes’?

 

DMG1993: I’ll respond to your question about using syringes in a separate post, here are suggestions on how to find a compounding pharmacy:

 

https://www.wikihow.health/Find-a-Compounding-Pharmacy

 

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micedana:  Good to see you on the boards as always! Thank you for sharing the lessons you have learned about finding and working with a compounding pharmacy as well as making and using your own do-it-yourself (DIY) suspension.  Did you mean to write ‘You can buy 1mL syringes’ instead of ‘You can buy 100mL syringes’?

 

DMG1993: I’ll respond to your question about using syringes in a separate post, but wanted to share some tips on how to find and vet a compounding pharmacist:

 

(1) Gather leads.

 

- Ask your prescriber. [Not an option for you, unfortunately.]

- Ask your pharmacist.

- Contact pharmacies associated with hospitals (especially children’s hospitals) as well as those that work with long-term care facilities.

 

(2) Begin the vetting process (online search).

 

- Does the pharmacy specialize in compounding?

- Is the pharmacy USP 795 compliant? USP 797 compliant?

- Is it accredited (e.g. PCAB)?

- Does it belong to one or more professional associations (e.g. PCAA)?

- Is there any evidence the pharmacy has ‘issues’ (e.g. unhappy customers, quality concerns, business problems)?

 

(3) Continue the vetting process by contact the pharmacy. 

 

Ask to speak to the lead pharmacist not a tech.  Explain that you are looking for a compounding pharmacy to work with long-term on a gradual, symptom-based taper from whatever benzodiazepine you are taking.  (Compounding pharmacies are businesses.  Learning that you are a potential long-term customer should get their attention.)

 

Questions to ask:

- Do you have access to a stability-tested liquid formulation for my benzodiazepine? Does the formulation yield a solution or a suspension? What is the concentration? What are the ingredients?

- What does the formulation use as the drug source? API (active pharmaceutical ingredient) or commercial product (tablets, capsules)?  If the latter, will you be willing to use tablets/capsules from my current manufacturer?

- Do you or a member of your staff have experience preparing this formulation?

- What steps would you take to ensure that the liquid you prepare will have consistent properties from batch to batch?

- Will you ft the bottle you use to dispense the liquid with an appropriately sized press-in bottle adapter to make it easier to measure the liquid?

- Will you provide me with high quality oral syringes with the appropriate nominal volume and graduations to measure the liquid as accurately as possible? Will you instruct me on how to properly use these devices?

- My prescriber does not have experience with compounding. Would you be willing to tell me exactly what s/he would need to write on the prescription?

- Can you give me an estimate of how much my out-of-pocket cost will be per fill?  With my insurance?  Without insurance?

- Do you offer a discount or program for long-time customers?

 

Thank you , this is very helpful.

There are at least 10 within my immediate area so I'll make some calls tomorrow.

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Re: your question about how you would accurately measure 4.45mL with a syringe ….

 

The accuracy of a dose depends on:

 

(1) the degree to which each ‘unit’ of the dosage form contains the amount of drug on the label. The likelihood of obtaining an accurate dose is highest when using unmodified/unmanipulated commercially manufactured dosage forms (e.g. tablets, ODTs, oral solutions).  DIY dosage forms involving drug manipulation are less accurate. Professionally formulated and compounded dosage forms are probably somewhere in between.

 

(2) the tools we use to physically measure the dose.  For example, the fact that you can move the plunger in a syringe to a particular mark on its scale does not necessarily mean you are accurately measuring that amount, especially at the lower end of the scale.

 

Here’s an overview of syringe accuracy written by a PharmD:

 

Syringe Accuracy

 

There is an ISO standard (ISO 7886-1) that describes acceptable accuracy of a sterile disposable syringe. To get the whole thing you have to purchase it. The short story here is:

* The most accurate syringe in common use has an accuracy of ±4% when its nominal volume is 5 mL or greater when delivering at 50% or more of its nominal volume.

* This means that (for example), if we fill a 10 mL syringe to its 10 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 9.6 mL and 10.4 mL.

* This means that (for example), if we fill a 50 mL syringe to its 50 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 48 and 52 mL.

* Syringes below 5 mL are accurate if they can deliver within ±5% when measuring 50% or more of their nominal volume. For a 1 mL syringe, this means that we know, at best that measuring a 1 mL volume in that syringe will deliver somewhere between 0.95 and 1.05 mL.

* Below 50% of its nominal volume, the accuracy of the syringe declines with the volume measured until, at 10% of its nominal volume, it delivers ±16% accuracy. So when measuring a volume of 0.1 mL in a 1 mL syringe, the best you can actually know is that you are delivering somewhere between 0.084 and 0.116 mL. At 20% of its nominal volume, such a syringe delivers ±9.5% of its apparent measured volume, so, if we were to set ±10% as our acceptable standard of accuracy, then the lowest volume we can accurately measure with any syringe available to us is 0.2 mL

 

Of course, these numbers are ranges, and any given syringe may be anywhere within this range. These numbers presume measurement to a gradation on the syringe scale. Interpolation between those gradations creates additional error. Further, the inherent error in the performance of the syringe itself makes such interpolation nonsensical. For example, interpolating between the 9.8 mark and the 10.0 mark on a 10 mL syringe, even correctly positioned, only places you somewhere between 9.5 and 10.3 mL.

 

Source:

the illusion of accuracy

https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy

 

Given the above, the best we can do is:

 

(1) Use a high quality syringe, preferably one that has been tested per ISO BS/EN ISO 7886-1.

(2) Use the smallest volume syringe that will measure the entire dose.

(3) Measure to, rather than between the lines, rounding values as appropriate.

 

To measure 4.45mL, you would use a 5mL syringe.  If that wasn’t an option, your next choice would be a 3mL syringe (you would have to draw two doses — one of 3mL and one as close as you can get to 1.45mL using the gradations on the syringe).

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Re: your question about how you would accurately measure 4.45mL with a syringe ….

 

The accuracy of a dose depends on:

 

(1) the degree to which each ‘unit’ of the dosage form contains the amount of drug on the label. The likelihood of obtaining an accurate dose is highest when using unmodified/unmanipulated commercially manufactured dosage forms (e.g. tablets, ODTs, oral solutions).  DIY dosage forms involving drug manipulation are less accurate. Professionally formulated and compounded dosage forms are probably somewhere in between.

 

(2) the tools we use to physically measure the dose.  For example, the fact that you can move the plunger in a syringe to a particular mark on its scale does not necessarily mean you are accurately measuring that amount, especially at the lower end of the scale.

 

Here’s an overview of syringe accuracy written by a PharmD:

 

Syringe Accuracy

 

There is an ISO standard (ISO 7886-1) that describes acceptable accuracy of a sterile disposable syringe. To get the whole thing you have to purchase it. The short story here is:

* The most accurate syringe in common use has an accuracy of ±4% when its nominal volume is 5 mL or greater when delivering at 50% or more of its nominal volume.

* This means that (for example), if we fill a 10 mL syringe to its 10 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 9.6 mL and 10.4 mL.

* This means that (for example), if we fill a 50 mL syringe to its 50 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 48 and 52 mL.

* Syringes below 5 mL are accurate if they can deliver within ±5% when measuring 50% or more of their nominal volume. For a 1 mL syringe, this means that we know, at best that measuring a 1 mL volume in that syringe will deliver somewhere between 0.95 and 1.05 mL.

* Below 50% of its nominal volume, the accuracy of the syringe declines with the volume measured until, at 10% of its nominal volume, it delivers ±16% accuracy. So when measuring a volume of 0.1 mL in a 1 mL syringe, the best you can actually know is that you are delivering somewhere between 0.084 and 0.116 mL. At 20% of its nominal volume, such a syringe delivers ±9.5% of its apparent measured volume, so, if we were to set ±10% as our acceptable standard of accuracy, then the lowest volume we can accurately measure with any syringe available to us is 0.2 mL

 

Of course, these numbers are ranges, and any given syringe may be anywhere within this range. These numbers presume measurement to a gradation on the syringe scale. Interpolation between those gradations creates additional error. Further, the inherent error in the performance of the syringe itself makes such interpolation nonsensical. For example, interpolating between the 9.8 mark and the 10.0 mark on a 10 mL syringe, even correctly positioned, only places you somewhere between 9.5 and 10.3 mL.

 

Source:

the illusion of accuracy

https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy

 

Given the above, the best we can do is:

 

(1) Use a high quality syringe, preferably one that has been tested per ISO BS/EN ISO 7886-1.

(2) Use the smallest volume syringe that will measure the entire dose.

(3) Measure to, rather than between the lines, rounding values as appropriate.

 

To measure 4.45mL, you would use a 5mL syringe.  If that wasn’t an option, your next choice would be a 3mL syringe (you would have to draw two doses — one of 3mL and one as close as you can get to 1.45mL using the gradations on the syringe).

 

Understood, thank you.

Do you have any links to good 5mL syringes, assuming I will get a compounded solution from the pharmacy?

You also noted that they may be able to provide this, so I will ask them.

 

Thanks again.

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You’re most welcome.

 

The compounding pharmacies I’ve worked with use Medisca and/or BD oral syringes.  We have members who have used Baxter (or BAXA) ExactaMed.

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-Sorry, I meant 1ml syringes.  :idiot:

-You use them of course when the dose is less than 1 ml. I use them too at 0,125 ml pulling liquid twice. I admit that the more precise the better but the

main thing is that you are reducing and the amount of imprecision shouldn't affect you.

-It's hard to find 0.001 ml marks syringes. As I said above they come in 0.002 ml marks. This is of course for the 1 ml Syringes. The ones in amazon may show 0.001 marks but when you get them they are 2's. So be careful.

- Another important thing is to ask the pharmacy to give you a dark bottle -they normally do- preferably with a self press in bottle adapter. If they don't have

it you can buy them on eBay or amazon. Just measure the neck of the bottle. Normally they are 22-24-28 mmm. Careful! some have the hole and not the

press valve!

-I think I already say it, but if I were you I would hold for a while during the liquid till I'm sure everything is ok. So you can check how you react to liquid

without reducing it.

-Last, get everything you need and don't be too obsessive about it. The main thing is that you will have the tools to reduce it very slowly and more practical and precise.

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Re: your question about how you would accurately measure 4.45mL with a syringe ….

 

The accuracy of a dose depends on:

 

(1) the degree to which each ‘unit’ of the dosage form contains the amount of drug on the label. The likelihood of obtaining an accurate dose is highest when using unmodified/unmanipulated commercially manufactured dosage forms (e.g. tablets, ODTs, oral solutions).  DIY dosage forms involving drug manipulation are less accurate. Professionally formulated and compounded dosage forms are probably somewhere in between.

 

(2) the tools we use to physically measure the dose.  For example, the fact that you can move the plunger in a syringe to a particular mark on its scale does not necessarily mean you are accurately measuring that amount, especially at the lower end of the scale.

 

Here’s an overview of syringe accuracy written by a PharmD:

 

Syringe Accuracy

 

There is an ISO standard (ISO 7886-1) that describes acceptable accuracy of a sterile disposable syringe. To get the whole thing you have to purchase it. The short story here is:

* The most accurate syringe in common use has an accuracy of ±4% when its nominal volume is 5 mL or greater when delivering at 50% or more of its nominal volume.

* This means that (for example), if we fill a 10 mL syringe to its 10 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 9.6 mL and 10.4 mL.

* This means that (for example), if we fill a 50 mL syringe to its 50 mL mark and we all agree the syringe is full (contains no significant air), the best we can know is that the syringe contains somewhere between 48 and 52 mL.

* Syringes below 5 mL are accurate if they can deliver within ±5% when measuring 50% or more of their nominal volume. For a 1 mL syringe, this means that we know, at best that measuring a 1 mL volume in that syringe will deliver somewhere between 0.95 and 1.05 mL.

* Below 50% of its nominal volume, the accuracy of the syringe declines with the volume measured until, at 10% of its nominal volume, it delivers ±16% accuracy. So when measuring a volume of 0.1 mL in a 1 mL syringe, the best you can actually know is that you are delivering somewhere between 0.084 and 0.116 mL. At 20% of its nominal volume, such a syringe delivers ±9.5% of its apparent measured volume, so, if we were to set ±10% as our acceptable standard of accuracy, then the lowest volume we can accurately measure with any syringe available to us is 0.2 mL

 

Of course, these numbers are ranges, and any given syringe may be anywhere within this range. These numbers presume measurement to a gradation on the syringe scale. Interpolation between those gradations creates additional error. Further, the inherent error in the performance of the syringe itself makes such interpolation nonsensical. For example, interpolating between the 9.8 mark and the 10.0 mark on a 10 mL syringe, even correctly positioned, only places you somewhere between 9.5 and 10.3 mL.

 

Source:

the illusion of accuracy

https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy

 

Given the above, the best we can do is:

 

(1) Use a high quality syringe, preferably one that has been tested per ISO BS/EN ISO 7886-1.

(2) Use the smallest volume syringe that will measure the entire dose.

(3) Measure to, rather than between the lines, rounding values as appropriate.

 

To measure 4.45mL, you would use a 5mL syringe.  If that wasn’t an option, your next choice would be a 3mL syringe (you would have to draw two doses — one of 3mL and one as close as you can get to 1.45mL using the gradations on the syringe).

 

Hi,

 

I found a pharmacy that checks all of the boxes, thank you for the questions to ask.

When I mentioned I was trying to taper with a jewelers scale, she gasped.

 

My psychiatrist first told me I could withdraw in a month (LOL), then he said that my taper with the jewelers scale was good, but really slow (LOL), then told me that he doesnt know how to get a solution for clonezepam.

 

You are much more knowledgeable than my psychiatrist it seems.

 

Thank you

 

 

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Thank you for the good news update, DMG1993.  Tip of the hat for conducting the due diligence required to find a compounding pharmacist that checks all the boxes.  A caring and competent compounding pharmacist can be a valuable ally during benzodiazepine discontinuation. 
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