Help w/lorazepam taper: switching to liquid??

[[Buddie]]

Hi everyone,

I have tapered from 3mg to 2.5mg lorazepam sublingual 1 year ago, and held my taper up until now (10 months), which is causing lots of issues (possible interdose and tolerance withdrawal, very intense symptoms, unable to get out of bed and function). I'm in a really awful place and I just want to get back on track. I have questions about how to proceed and get on a good plan moving forward.

I'm at the place where I recognize that my sublinguals are really not sustainable for a taper: due to how small they are, and they crumble so easily.
I've been trying to weigh out my options:

(1) Switching to the oral tabs and beginning a dry cut taper down. I got a supply of oral 0.5mg tabs yesterday and they are not much bigger than the sublinguals! I was told that it's only the 1mg tabs that are rectangular-oblong, and I'm not sure those would be ideal for my situation anyway. I'm not sure if it is ideal to work with the tabs overall, and I've seen some comments being concerned with how much drug is actually in the pills - can someone explain what they mean by this?

(2)I spoke to a compounding pharmacy, and they can take the oral tablets (same manufacturer as the oral, not sublingual) and put them in suspension. The pharm says it's 0.1mg per 1ml, and they dispense the liquid every 2 weeks to maintain freshness. I asked what is in the liquid, and I was given. runnaround, just told that it's a suspension (not helpful). He was also not able to tell me about how the liquid might different from the pill, as he said that I should detect the drug the same.
I am nervous about switching to either of these new formulas, but moreso the liquid. I'm nervous that I will have issues with the tablet dosing, scaling and shaving them. I would say I am very anxious about adjusting to liquid, if it will worsen my symptoms or not work for me. But at the same time, I want to get on a method that is going to allow me the precision and ease I need to continue tapering! I've read that the liquid pharmacokinetics are different to solid dosage, and. it is suggested to increase the dose slightly - can someone please explain this to me?

My current regimen is as such:
0.5mg morning, 0.5mg afternoon, 1.5mg bedtime (sublingual tabs)
Based on how the pharmacist said, I'd be taking 5ml morning and afternoon, and 15ml bedtime (if I go with the liquid), but not accounting for any possible differences...it is a lot of liquid to dispense.
Since the concentration is 0.1mg per 1ml, I am wondering how I can achieve super small decreases, such as 3% (I've had so many symptoms, I want it to be undetectable at first!) - would this be related to the types of syringes I can find and just be as precise as I can?

Slightly unrelated to titration...but since I rapidly tapered and held my dose for so long causing lots of intense withdrawals, I wonder if it might be best to updose back to my original dose, and then decide my method, and start coming down again correctly, with the small increments I wish I'd have known in the beginning? I know it's not favourable, but I've had such a rough time after holding the lowered dose for 10 months, I just wonder if it's going to cause more destabilization... -if someone could please weight in on this?

I would appreciate any insights or information on this topic. Thank you so much!

[[Buddie]]

Libertas has been helpful for me in the past when I was using tablets and helped me understand what to ask for liquid compound and guided me so hope he can chime in here and help give his thoughts!! Thanks Libertas .

[[Buddie]]

I wouldn't increase your dose, some members have actually felt relief when they're lowered their dose after holding for a long time.  I don't know what country you're in but Ativan does come from the manufacturer in liquid form.

1. I don't think you need to worry about the actual drug in the tablets, I believe that's fairly consistent but the amount of actual medication can't be guaranteed when you split it if it's not scored. 

2. I've read from members that switching to liquid can mean a change in onset of action and duration but it seems like you going from sublingual to liquid the onset wouldn't be that different.

I believe some members have diluted their compounded medication with water to achieve smaller reductions.

[[Buddie]]

Hi [...],

Unfortunately I seem to be having the opposite effect when I decrease, or the withdrawals catch up to be 1.5-2 weeks later and they're very intense as if I stopped my medication altogether. That's why I'm having a hard time with this...

1. This is the main issue with the tablets- they are not scored. They are too small. Sublingual pills and oral 0.5 are not scored. I will attach a photo to show everyone what I mean! These pills are like little bullets!

2. According to the pharmacist, they are using a specific generic (same as the oral tablets, not sublingual) for the liquid. So the difference will literally just be in switching formula regardless, which has to happen anyway. I understand that there may be a little adjustment to the new pill, but I am definitely hoping it won't be that different.

My photo: I've labelled the 2 sublingual strengths, the oral tab, I've put 2 Wellbutrin pills on the bottom and a little assortment of almond, pumpkin and sunflower seed and AirPod to try and give scale. I hope this helps...my pills are not scored, right? I believe that the liquid is the way to go since these pills are too small.

Link to photo: https://imgur.com/a/b03TXry

[[Buddie]]

Thanks for the photo, I'm surprised they're not scored.  It looks like liquid is the way to go but I'm worried about you stressing over this, it could make your transition more difficult. 

[[Buddie]]

I agree with both things you've said. I just feel that since the pills are really difficult to work with, that also causes A LOT of stress and maybe inaccurate dosing (which I already had attempting the rapid taper with the sublinguals!). I realize that at this point the formula has to change regardless and it should be the liquid to be more accurate and controlled. I will have to accept that there will be a transition, and that I'm doing it for my good.
Thanks for your insight!

[[Buddie]]

Regarding the liquid: if the pharmacist says it's a suspension it means the pill doesn't completely dissolve in the liquid. So basically in layman's terms your benzo is not equally distributed in the liquid. Most of the time to limit the possible effects of this type of liquid we use a combination of liquid and pills to taper.

How it works is you only take part of the dose you want to taper in liquid form and the other doses you take in pill format. Let's say you want to taper your evening dose. This is an example only: you'll take your morning 0.5 and your afternoon 0.5 in pill form. Then you'll take your evening 1mg in pill form and take 0.5mg in liquid. The 0.5mg liquid portion is the part that you'll be tapering.

I hope my explanation is making sense.

[[Buddie]]

We are taking same sublingual ativan. My compounding pharmacy used same sublingual ativan
to make suspension liquid for me.  I just started to slowly transfer to liquid. You should ask your pharmacist
to make sublingual liquid. I am in Canada.

[[Buddie]]

[...],

That makes a lot of sense, thank you for bringing up that point. I will consider this for how I reduce.
I got a script of the oral tabs yesterday and I wonder if it's worth switching over to them, or keeping the sublinguals for the majority of my dosing? Supposedly, the compound pharm said he is using a specific generic to compound, which is what I requested in oral tabs. But if I keep the majority of my dosing to pills, should I keep the same sublingual formula? Or since I am taking the liquid does it warrant the change to the same oral tab both taken as a pill and liquid? Sorry, I hope this makes sense!

Sherri li,

That is very interesting that you are able to use the sublingual Ativan! My compounding pharm was very strict about what he is using, he kept redirecting me on that. I kept asking him if it was possible to use the sublinguals since I was sensitive/used to them, and it didn't get me anywhere. I am in ON, Canada.
Can you tell me about your experience using the liquid? Like, were you initially on the SL tablets and switched over to liquid to taper? What is your dose/dosing, and how slow are you transferring? How is it going for you? Would really appreciate any help/info since you're on the same benzo as me!!

[[Buddie]]

 I am in Toronto. I am taking Sublingual Ativan for short period (around 4month) and low dose.
Currently dose is 0.5mg per day. I will start to typer when transfer from tablets to liquid. First I switched
afternoon dose for a few days, now I am switching morning dose. The pharmacist told me to put
the liquid under tongue for 3mins and swallow. So far I feel ok. I know most pharmacy don't use SL ativan to make liquid. But this pharmacy did. On their website, this pharmacy is only PCAB accredited pharmacy in Canada.