CLONOPIN HELP! I can’t figure out taper dosage. Where is everyone?

Hi MS,

Unfortunately the link didn’t come through. Maybe it just didn’t paste correctly, but I can’t see anything. 🤷🏻‍♀️

I’m vexed. I hear what you’re saying and it makes sense. Those who have done liquid takers make it seem so simple, but it really doesn’t seem very precise to me. Then again, my scale (house) issues are making me doubt my dose weights every single day. I’m not sure which way to go. I don’t mind the cut and weighing, but I feel defeated. I’m wondering if I’ll have to find a way to pay for compounding. Here in the US Medicare health insurance refuses to help pay for the cost. They used to. I’d rather see work being done to fix this and other major issues here than just adding “black boxes” that no doctor will ever read (though a most important message). I’m going to get in touch with someone at Benzodiazepine Coalition here in my state. Really, it should NOT be this hard just to get a liquid drug form if it’s chemically possible, and it is.

Sorry. I’m really stressed out because I have to weigh my pills for this week today and I don’t trust the weights at all.

:-(

I do appreciate your taking the time to educate me. ❤️

Unfortunately the link didn’t come through. Maybe it just didn’t paste correctly, but I can’t see anything.

Here is the link I believe Winters sun intended to share with you:

He is correct that there are ‘gotchas’ associated with the approach shown in the video. However, the approach can be altered to address at least one of them.  You are correct to question the accuracy and precision of do-it-yourself liquids.  First, there’s no guarantee that each and every milliliter of the liquid contains exactly the same amount of drug.  Second, just as there is measurement error associated with using digital scales to measure solid dosage forms. there is also measurement error associated with using oral syringes to measure liquid dosage forms.

I’m wondering if I’ll have to find a way to pay for compounding. Here in the US Medicare health insurance refuses to help pay for the cost. They used to.

Hmmm … might I ask where you got this information?

Per the source below, Medicare Part D drug components (see note), including components used as vehicles in a compound, may be billed under Part D.  Also, the dispensing fee may include labor costs associated with mixing a compounded drug product that contains at least one Part D drug component. 

Note: Bulk powders (i.e., Active Pharmaceutical Ingredient) do not satisfy the definition of a Part D drug and are not covered by Part D.

So, for example, per the source below, a compound that uses generic or brand name tablets/capsules as the drug source would be covered under Medicare Plan D.  But a compound that uses the bulk powder (i.e. the Active Pharmaceutical Ingredient or pure drug substance) would not.

Fwiw … my experience with compounding is that costs can be quite reasonable, even if one has to pay out of pocket (see note to non-Medicare readers).  For example, if one uses a combination of regular tablets and compounded liquid (i.e. take part of the dose in regular tablet form and use the liquid to taper), a 4-8 week supply of a compounded liquid made with brand name tablets might cost in the range of $50 (much less than what some members pay for supplements and alternative therapies).

Note to non-Medicare readers: Non-Medicare health insurance may cover all or part of the cost of compounding. Contact your plan’s Pharmacy Benefits Manager for specifics.

Source:

Medicare Prescription Drug Benefit Manual Chapter 6 | Part D Drugs and Formulary Requirements | 10.4 Extemporaneous Compounds

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf

Hi Libertas!

Thank you for all the information. I have seen that water taper video and yes, it does seem like there are huge possibilities for inconsistencies. As to the Medicare, I don’t have Part D. I have a separate prescription plan that I pay extra for as well as a supplement for regular HC. I have talked with my insurance companies and they aren’t being very helpful. Customer service is not good. I think I’ll speak with my local pharmacist, but when I phoned, Walgreens Specialty Pharmacy in my state (MA) they quoted me $300 for what typically cost me $12 per month in tablets. I’m going to speak with my therapist about this. I’m at 0.264g or so right now, so I suppose I could get a liquid script for 0.75mg and dry cut the rest and then figure out how to taper approx 5% per month (from latest dose). It seems daunting. I just ordered yet another scale, but I really don’t know what the main issue is. My brain struggles with math. Im sorry if my problems getting a consistent dose annoys people. Trust me, I am dreading weighing out my next week of pills.

❤️

$300 a month for a compound is outrageous.  It sounds to me like you need to find another compounding pharmacy. Below is a link with suggestions on how to do so.

What is your total daily dose in milligrams of drug/API (not pill weight)?

How many milligrams of drug do you take at what times?

I’m asking these questions so I can get a sense of whether using a combination of regular tablets and a compounded liquid is a possibility for you.

Link:

How to Find a Compounding Pharmacy

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

$300 a month for a compound is outrageous.  It sounds to me like you need to find another compounding pharmacy. Below are suggestions on how to do so.

 

What is your total daily dose in milligrams of drug/API (not pill weight)?

 

How many milligrams of drug do you take at what times?

 

I’m asking these questions so I can get a sense of whether using a combination of regular tablets and a compounded liquid is a possibility for you.

 

 

Finding and Vetting a Compounding Pharmacist

 

(1) Gather leads.

 

- Ask your prescriber.

- 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 contacting 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?  Would you be willing to set aside a bottle for use just in my compound?  Would you be willing to let me know when there is a batch change?

 

- 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 fit the dispensing bottle 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?

- Will you be willing to help me with math if needed?

- 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-term customers?

Wow! You must be an expert on this. Thank you! I’m printing this out for my phone calls. I did get another compounding pharmacy name, but I did not like the reviews. I’ll need to figure out a taper plan as well. Good idea to only speak with the pharmacist. Sweet talk, of course.

Is it possible to not microdose with a compound, meaning can one cut 5% each month or is that impossible?

I don’t know exact mg amount I’m taking, around 0.8125 mg I think based on tablets: 0.5 mg + 0.25 mg + approx 1/3 to 1/4 of 0.25 mg.

It’s approx 0.264 grams in weight. I eyeball and shave off, but… scale issues.

Thank you. I had no idea it would be this involved.

You’re welcome!

Re: your question about microdosing …

Are you referring to daily microtapering?  If so, there is no requirement to daily microtaper when using a compounded liquid (or any other dosage form for that matter).  You can use whatever percent reduction and reduction interval work for you and the pharmacokinetics of the benzodiazepine you are tapering.

Re: a taper plan …

Here’s an example of a Phase 1 taper plan using a total daily starting dose of 1mg of clonazepam divided into 3 doses.

Split a 0.5 tablet into quarters. (Clonazepam has a relatively long half-life plus you will be consuming the entire tablet over the course of a day so it’s ok if the pieces are not exactly the same size.)

Dose and taper as follows:

0.25mg in tablet form*+ 0.25mg in liquid form, taper liquid to zero as tolerable

0.125mg in tablet form + 0.125mg in liquid, taper liquid to zero as tolerable

0.125mg in tablet form + 0.125mg in liquid, taper liquid to zero as tolerable

*Take two of the 0.125mg pieces resulting from splitting the 0.5mg tablet into quarters

The amount of liquid ingested will depend on the concentration of the liquid.  If a 0.1mg/mL liquid is used, the starting doses would be be 2.5mL, 1.25mL, and 1.25mL.

Wow, you’ve really gone all out here, Lib!

Thank you for providing CKing with such valuable information. You are so greatly appreciated!

You’re welcome!

 

Re: your question about microdosing …

 

Are you referring to daily microtapering?  If so, there is no requirement to daily microtaper when using a compounded liquid (or any other dosage form for that matter).  You can use whatever percent reduction and reduction interval work for you and the pharmacokinetics of the benzodiazepine you are tapering.

 

Re: a taper plan …

 

Here’s an example of a Phase 1 taper plan using a total daily starting dose of 1mg of clonazepam divided into 3 doses.

 

Split a 0.5 tablet into quarters. (Clonazepam has a relatively long half-life plus you will be consuming the entire tablet over the course of a day so it’s ok if the pieces are not exactly the same size.)

 

Dose and taper as follows:

 

0.25mg in tablet form*+ 0.25mg in liquid form, taper liquid to zero as tolerable

0.125mg in tablet form + 0.125mg in liquid, taper liquid to zero as tolerable

0.125mg in tablet form + 0.125mg in liquid, taper liquid to zero as tolerable

 

*Take two of the 0.125mg pieces resulting from splitting the 0.5mg tablet into quarters

 

The amount of liquid ingested will depend on the concentration of the liquid.  If a 0.1mg/mL liquid is used, the starting doses would be be 2.5mL, 1.25mL, and 1.25mL.

Agreed! Wow! Thank you so, so much for all of the guidance - all of you! I wish I’d had this knowledge sooner, but shit happens and things change. The compounding search continues. I’m hoping my many requests won’t be met with a hang up.    This morning, back to the inaccurate cutting and weighing doses for the next week. 😩

❤️ to you all