Compounded Pharmacy

Hi everyone. I was on Xanax for 20 plus years. My doctor and I are working on a slow taper. The first thing we did was move me over to the equivalent dose (4mg per day) of Klonopin. This first month my only job is to stabilize on the 4mg per day dose. My pattern has been to take extra when I've had a bad day, but then take less on good days. The way it works out is I will start my actual taper on January 1, 2021. Since I take 2 tablets per day (both at bedtime), the first thing I am going to do is cut my dose down to one pill within the second month. On the third month I hope to begin the titration with just one 2mg tablet. I really could use the spreadsheet. I will also probably need some help with that as well. I have watched a few UTUBE videos where you discard 1ml the first day; 2ml the second day; 3ml the third and so on and so on. I think that might be a good plan for someone who hasn't been on such a high dose for such a long time, but I feel like that might be too rapid for me. That's where the spreadsheet comes in. Would someone be willing to help me with the spreadsheet. Please. 

 

Thank you and God Bless.

Before we discuss using liquid to taper we need to discuss your plan.

 

Are we to understand that you'll stabilize on the 4 mgs of Klonopin a day, meaning you won't take more one day and less the next?

 

I feel reducing your dose by 2 mgs in one month is too fast, if you've been on benzo's for 20 years you may experience intolerable symptoms. 

 

Can you get smaller dose tablets for an easier taper?

 

As for a spreadsheet, a taper plan is a good idea but tapers need to be adjusted from time to time so don't fall in love with a ridged schedule, listen to your body.

Thanks for the reply. Yes, you are correct about the stabilization period. I am utterly and totally confused about how to do the spreadsheet. Honestly, in order to put it to use, someone will need to put it together for me--perhaps for the first 30 days. I don't understand how I will know when I am done with the liquid part which will essentially be the end of my taper. I don't know how much to withdrawal from the syringe and discard every day. I don't know how many times a day to dose. I am working with my doctor and he said we can go as slow as necessary to keep me as comfortable as possible. I need guidance on dosing and supplies. What size syringe(s) do I need? How many times a day should I dose? My doctor is awesome, but he isn't going to be able to help me with these types of details. I originally went to him with the Ashton protocol in hand. As have three or four other doctors along the way, he wanted nothing to do with it. He said it would be too time consuming to figure out. My doctor before him said he wasn't comfortable implementing a plan where I am ADDING a new benzo to a CURRENT benzo. So this liquid titration method is my best bet. I absolutely must do this. My memory is already slipping and I owe it to the people I love to stay lucid as long as possible.

I can see you're overwhelmed but we have plenty of time to work this out, okay?

 

Before we get too far down this path let me ask if you have a compounding pharmacy near you and if your Dr would be willing to write you a script to get your medication professionally compounded.  This would be the most reliable and accurate route for you, you wouldn't have to do anything but take your dose, let us know.

To answer your questions: Yes. I have a compounding pharmacy about 15 minutes from my house. As for my doctor, I sent him an email and asked him if he would be willing to write the prescriptions to be compounded. He hasn't responded yet. He may be waiting until the end of the day to respond since he sees patients all day. I will let you know as soon as I hear from him.

While we're waiting perhaps you could tell us a little more about your situation.

 

How were you transitioned from Manx (Xanax?) to Kingpin (Klonopin?), am I correct in my guess that these are the benzo's you're referring to?  Was it a gradual switch over days or weeks or was it all at once?  Do you feel you were switched to an adequate amount of Klonopin?

 

Depending on how your crossover was done, it could take a month or more to stabilize. Your job right now is to focus on stabilizing on the Clonazepam. 

 

I would suggest you start keeping a journal about how you're responding to the switch from X to K.  It’s particularly important to keep track of how you're responding to the Clonazepam.  About how many hours to peak effect?  How do you feel when you wake up?  How do you feel as the day progresses?  You'll need to have this info to inform your decision about whether or not you should dose multiple times a day.    For example, you might benefit from moving to at least twice a day dosing to address your anxiety.

 

This is just the first part of our conversation so I hope you'll keep engaging so we can help you get comfortable with your taper.

 

 

 

 

It is 7 pm (PST) right now and I haven't heard back from my doctor. If I don't hear from him by noon tomorrow I will give him a call. To answer your other questions:

 

Yes. I meant Xanax and Klonopin. I don't know if there is an auto-correct feature on here because I thought I proofed it pretty well.

I always take the 4mg at bedtime. On bad days I would take an extra pill (2 mg) (during the day) just to calm down.

I switched to Klonopin in early September. I went from 4 mg per night of Xanax to 4 mg per night to Klonopin. I have done quite well on it. My anxiety is triggered by a number of things. I don't handle change very well. Even a good change can cause me anxiety. December has been much better. Probably because I am taking the Klonopin consistently as opposed to 3 mg's some days and 4mg's on others. I have been consistent since December 1st so I think I will be adequately adjusted by January 1.

 

I have a few more questions because I am pretty sure my doctor will ask it: If he agrees to write the prescription to be compounded:

1) What would the starting dose be considering I have been on 4mg for one month?

2) How would the dose reductions work? I am assuming it would be some sort of percentage over the course of a certain amount of time. I really do not want my taper to go past a one-year period. I would be most happy with nine to twelve months.

3) Would I be reducing every day? Every week? I feel pretty sure he will call the prescriptions in as needed--as long as he knows what dose I am at.

4) I think it's important to note that I have pretty much always taken my entire dose for the day at bedtime and rarely, if ever, feel intra-dose withdrawals. However, during the taper I realize it might be better to spread it out over the course of a day. I'm open to suggestions.

 

 

Its good to hear the transition to Klonopin has been fairly uneventful.

 

Before you call your Dr again I wonder if you might ask him for a combination of smaller dose pills as well as a compounded script.  You're on such a high dose of Klonopin that you can successfully dry cut your dose by quite a bit before employing the liquid prescription.

 

1. Hopefully he'll keep you on the 4 mg for a week or so to make sure you have a smooth transition to the liquid, I've read some members say there is a bit of an adjustment period.

 

2. We can help you with the percentages of your dose reductions, but predetermining the length of your taper isn't the best way to approach this, a taper that is driven by symptoms will keep you functional which is the point of tapering.  There is healing to be done even after the taper is over so rushing to get off the drug serves no purpose because once off, you can no longer mitigate the symptoms with the drug.

 

3. Some people reduce a small amount each day, others weekly or even monthly, it all depends on what works best for you, you're the subject in the experiment.

 

4. I agree you may need to start taking your dose more often during the day, you'll know when it's time so I'm glad you're open to it.

My doctor responded early this morning and he said he thinks compounding is a good idea. He just needs to know what he needs to do. I am a little confused:

 

Will the dry portion of my taper be done by a compound pharmacist or will I be doing it myself? I prefer to let the compounding pharmacist do it so it will be more exact? Insurance does not cover compounding but I have the means to cover it so if compounding from day one will make it easier, I would prefer to do that.

 

If I start out on a liquid, what would be the dose? My doctor is totally awesome. I am certain he will allow me to stay at 4mg in liquid form for as long as I need to. If I start out dry cutting, or having it compounded (my preferred choice), what would be the dose for that.

 

How often will I be making cuts? Daily? Bi-weekly? Monthly?

 

As you can see, I am just now learning about compounding pharmacy. I know they do it for post-menopausal women but I've never had any personal experience with it.

 

I am really glad I started this when I did because we have time to put the plan in place and then start it on January 1. My doctor said we will work out all the details (including your instructions as to what he needs to do) at our next appointment which is on December 29th. As far as the assortment of lower-dose pills, what do you recommend? It comes in 0.125 mg; 0.25 mg; 0.5 mg; 1 mg; and 2 mg.

 

 

 

 

I'm glad we started working this too, tapers need to be well thought out and planned so you did good. 

 

I'm going to give you a possible scenario that will hopefully give you an idea of what you're looking at for your taper, this will help you see the need for smaller dose tablets which are a stable and reliable source for the medication.

 

4 mg

 

3.5mg in tablets + 0.5mg in oral suspension, taper the oral suspension from 0.5mg to 0

 

3mg in tablets + 0.5mg in oral suspension, taper the oral suspension to 0

 

2.5mg in tablets + 0.5mg in oral suspension, taper the oral suspension to 0

etc.

 

I'm running low on my limited knowledge of tapering so I've asked for help to guide you, so be patient, okay?

 

 

 

I can jump in tomorrow, but I'm exhausted tonight.  I volunteered to do piano for my old church.  Everything has to be recorded for zooming, and playing performer/producer/engineer kind of slammed me today.

 

PianoGirl has similar joys, I'm sure.

 

Oopsy - We can get you a spreadsheet and get you started, but I guarantee that you don't want me working with numbers right now.  Try to be as consistent as possible with your dosing for a while.  That's a good place to start.  If you have a little stress, try to work it out without up-dosing.

How is it going today?  Does it look like 4 mg is going to be a good starting point?

 

There are basically two approaches to doing these tapers -> solid or liquid.  Most people who do solids purchase a small milligram balance (~$25), and weigh out their doses each day.  It's pretty easy to do.  In theory, you could have a pharmacist prepare capsules with the desired dose in them.  That could be expensive, and honestly - you can do it just as accurately.  Still, it would be convenient.

 

If you go the liquid route, you can obtain a liquid of known concentration from your pharmacist.  Since you're starting out at 4 mg, a 1 mg/ml solution would work nicely.  You would dilute some of that solution into water, remove however much you want to cut, then drink the rest.  Again, you can make this liquid yourself, but obtaining it from your pharmacist will definitely make life easier.

 

Either method can utilize a traditional cut and hold or a daily micro taper.  The traditional cut and hold has you make reductions of around 5-10% every 10-14 days, depending on how you're feeling.  With the daily micro taper, you make very small reductions (0.5-1%) every day (again, depending on how you're feeling).

 

So to get a plan started, you need to decide on solid or liquid and whether you want to do a cut/hold or a daily micro taper. 

I am so grateful and appreciative of the help. With the help of Benzo Buddies I really feel like I can do this. I am definitely taking this taper very seriously. If I don't respond quickly to a post, please bare with me. My husband has active Covid-19 right now and he has been really sick. Today is the first day he is feeling better but he is still not completely symptom free. Mostly, he is just exhausted. Having said that, will I need all of the tablets you mentioned in the first month? If I am reading it correctly, the only part I need compounded is the .5 syrup. Is that correct? My doctor really is on board with whatever it takes to get me off benzos so I'm pretty sure he will write whatever he needs to write to make it work. Thanks again. Now that my husband is better I can check this more often, provided I don't get sick myself. I took a Covid test Monday night so I should be receiving my results today or tomorrow. Regardless, I am symptom free--praise God.

Since I had a little extra time I tried to figure out what to ask my doctor for the first month. My start date will be January 1, 2021. I am more than willing to do the 4 mg incorporating the liquid for a week or two. But then I need to know the tablet strengths and liquid I will need for the remainder of the first month. As I have stated before, I am not good with math so the safest and easiest thing to do would be for you to tell me what to ask my doctor for. I still need to find a compounding pharmacy that is willing and able to prepare the solution, so the sooner the better. I don't want to find myself on January 1 scrambling to find a pharmacist.

Hello, oopsydaisy.  I’m sorry to learn your husband contracted coronavirus but glad he is feeling better.

 

You are correct.  If you want to use the scenario Pamster described, the compounding prescription would be for the oral suspension (what you’ve referred to as syrup).  Your doctor would write a second prescription for the tablets.

 

Re: what combination of tablets to use ... your doctor may have preferences regarding how many tablets s/he feels comfortable prescribing at one time and/or what type of tablets (regular vs orally disintegrating). However, one possibility would be to start with 1mg tablets with a functional score line. When your total daily dose in tablets reached the 1mg mark, you could switch to lower dose tablets or just use the suspension.

 

Good for you for recognizing the importance of finding a compounding pharmacy that has the expertise, equipment, and experience to prepare a compounded liquid! A compounding pharmacist can be a valuable ally when tapering (e.g. s/he can help you figure out what combination of tablets to use when, teach you how to measure your dose properly using an oral syringe, help you with calculations when you need to make adjustments in your taper plan).

 

Are you in the US?  If so, a formulation for a stability-tested 0.1mg/mL compounded oral suspension of clonazepam is available.  You would want to find a compounding pharmacy that has access to and experience with preparing this formulation (or a formulation for a 0.1mg/mL oral solution of clonazepam).

My intention is to spend a week at 4mg, 3.5 in tablets and .5 in liquid which will be compounded by a pharmacist. On week two, I will actually start the reduction. My doctor is very much on board, I just don't know exactly what to ask him for. For instance, if I have 3.5 mg in tablets and will be titrating the liquid to 0, how does that work? Do I reduce the liquid by 1 ml per day? 1 ml every 2 days? Once we figure that out, how long do I stay at each dose? Also, what mg tablets should I ask him for? Since I will be at 3.5 mg in tablets for a certain amount of time, it would make sense to me that I would ask for an assortment of 2mg tablets; an assortment of 1 mg tablets; and an assortment of .5 mg tablets. The most tricky part for me is not knowing how long I will be staying on a particular dose and how to know when I've completed my liquid reduction and where to go from there. I realize I seem like an idiot, but I just need someone to put it together for me--including a way for me to keep up with my progress. There used to be the famous spreadsheet, but I was too dumb to figure it out and I don't know if it still even exists

I get it. I was hoping to play "Have Yourself a Merry Little Christmas" to put up on Facebook but I started too late to memorize it and I HATE turning pages. I still have a few days so I'm gonna try to get it done. It's a pretty easy piece so I should be able to pull it off.

My intention is to spend a week at 4mg, 3.5 in tablets and .5 in liquid which will be compounded by a pharmacist. On week two, I will actually start the reduction. My doctor is very much on board, I just don't know exactly what to ask him for. For instance, if I have 3.5 mg in tablets and will be titrating the liquid to 0, how does that work? Do I reduce the liquid by 1 ml per day? 1 ml every 2 days? Once we figure that out, how long do I stay at each dose? Also, what mg tablets should I ask him for? Since I will be at 3.5 mg in tablets for a certain amount of time, it would make sense to me that I would ask for an assortment of 2mg tablets; an assortment of 1 mg tablets; and an assortment of .5 mg tablets. The most tricky part for me is not knowing how long I will be staying on a particular dose and how to know when I've completed my liquid reduction and where to go from there. I realize I seem like an idiot, but I just need someone to put it together for me--including a way for me to keep up with my progress. There used to be the famous spreadsheet, but I was too dumb to figure it out and I don't know if it still even exists

 

oopsy, 

1) don't do what I originally did (originally came down way too fast).  You're very wise in knowing not to taper fast.  Right now you're creating a great opportunity by planning the "foundation" of the taper. 

2) Regarding the "assorted" tablet sizes - stick with only one tablet size + liquid.  In my state.....that's two specific prescriptions written by the doctor to the pharmacy.  It keeps things simple for the patient, doctor, pharmacy, insurance company, state law.

4) The strength of the liquid will be determined by you (members will help you). The strength can be 1 mg/1ml, .1 mg/1ml, 01mg/1ml, or any strength you feel comfortable with.  The pharmacy will provide the oral syringes and a compounded bottle of clonazepam. My compound liquid is simple - the bottle has an adapter at the top, which the syringe fits into perfectly.  I insert syringe, turn the bottle upside down and draw the liquid (per pharmacy instructions - which they will teach you)

3) The compound pharmacy is extremely helpful.  They want to help you. They'll appreciate the honesty.  Mine likes answering questions and addressing my concerns. 

4) Length of time on a dose - due to the 1/2 life of benzos, Ashton suggests 10-14 days (unless you do the .01mg/day).  Personally I agree and often hold longer.   

5) Spreadsheet..........attached is a link to Jim Hawk's video on the spreadsheet...and a link to the spreadsheet itself.  Please note others will help you with either Hawks spreadsheet or a comparable one.  Personally, I don't use a spreadsheet, but I certainly do have a journal and know exactly what my dose is and dates.

https://www.youtube.com/watch?v=nJXVi7GUGNY                  http://bzo.spes-lavaux.ch

6) Once you get started, calmness will come.  We all had to learn to ride the bicycle and it quickly got easier and easier.

7) One more thing which helped me tremendously - learn the Valium equivalency.

.5 mg K =10 mg V. 

.1 mg K = 2 mg V. 

It sounds simple to say "today I'll cut .5 mg Clonazepam"......until we realize we've lopped off the equivalency of 10 mg V all at once. 

Greetings everyone. I have five days left before I start my taper. I have consistently stayed on Klonopin 4mg per day for 26 days. I will not be taking anything other than Klonopin (I will not be doing a cross-taper). I will be taking some in tablet form and some in liquid form. I do not know how much to reduce my dose or how often. I have wanted to do this for such a long time but it seems so darned complicated. I am hoping someone will understand and help me figure it out ASAP because like I said, my appointment is Tuesday and I need to know what to tell him I need. I hope everyone had a nice Christmas. I just need someone to hold my hand through this. I also need the spreadsheet in order to keep up with it all. Thanks and goodnight.

If I recall, you were going to take 3.5 mg as a solid and taper 0.5 mg as a liquid.  Were you able to obtain the liquid formulation or will you need to make it from the pills?

 

As for the size and frequency of your upcoming cuts...  It's difficult/impossible to design a long-term plan because nobody knows how you will respond.  A lot of people try a 10% cut then wait a couple of weeks to see how that works out for them.  That might be a good first step.  Alternatively, you might try the daily micro-taper approach with very small reductions (0.5-1%) performed more frequently.  Have you decided between those two approaches?

Hello oopsydaisy,

 

I merged your new thread with your previous one for continuity purposes, it helps to have all of the information in one place.  To that end, please put your medication history in your signature so we can know at a glance what you're currently taking, how often, for how long and other medications which may have an impact on your taper.  Here are the instructions. Add your history/signature 

 

In order to help you effectively we'll need to know more about the liquid medication you plan to take, will it be stability-tested, what are the ingredients, and most important ... what is the concentration?

 

I would also encourage you to keep these practices in mind.

 

With your first reduction keep a close eye on your symptoms, write them down to include intensity, this will help you make a decision when it's time to reduce again.  Rigid time tables aren't encouraged, your taper should be symptom based so you can function.

Hi everyone. I started my taper last week. My anxiety is so ramped up I can barely walk because of shaky knees. So I went to the compound pharmacist and he prepared 4 capsules: Week one the dose is 3.75; week 2 the dose is 3.50; week 3 3.25; week 3.00 and on an on an on. You get it. This is not what I had in mind when thinking about the taper. I thought it would be the water method whereas I would take tiny (micro) cuts and instead of cutting every day, perhaps I could do a micro cut every 3 days or something The compounding pharmacist. I thought it would be easier to do a capsule because it could be taken once a day. That isn't working. My anxiety is on the ceiling!! I should have insisted on the liquid taper. However, even though yesterday was so difficult, I decided to stay the course. I called my regular pharmacist and and he said that my brain probably would not recognize that small of a cut and the anxiety was likely the product of the anxiety of coming off the medication. He also told me something very interesting, He said some pharmacist are better at compounding than others. He said it was unlikely, but possible, that it wasn't compounded correctly. Is there a way to microdose by taking the capsule and then dissolving? I don't want to wait three more weeks to switch over to the micro cuts. I emailed my doctor yesterday (twice) but haven't heard back from him. It took me YEARS to find a good psychiatrist. Now I'm afraid I'm going to get kicked out of his practice. I have been asking for the spreadsheet for a while and it seems like no-one wants to provide it to me. If someone is willing to help me with the spreadsheet, provided someone gives it to me, I will be fine. I'm stuck for three more weeks on the capsules. I will stay the course for now--even though I really have not. I am taking 3.75 right now. After 3 weeks have passed, I can speak with my doctor, of course, and see is if  we go use the liquid titration. I'll take any help I can get.

 

Hi oopsydaisy,

 

I need you to put your medication history in your signature so we can better help you, you don't mention what your benzo is but its Klonopin, right?  Here are the instructions.  Add your history/signature 

 

Two things jump out at me about your situation, once a day dosing might not be enough if you're experiencing interdose withdrawal and the reductions you have planned are too big and too fast. 

 

A third thing I need to mention is the pharmacist is wrong, your brain absolutely will notice the reductions and him telling you it's anxiety of coming off the medication is ignorant and demeaning. 

 

If you're considering changing the compounded capsules you're paying good money for by breaking them up I'd advise against it, why pay the money if you're going to redo them?  You can ask for any dose reductions you want as long as your Dr is on board, they can be very small reductions that won't hurt nearly as much.  Or you could ask for a liquid version so if you do want to slow down, you can do it easier.

 

As for a spreadsheet, what good is a spreadsheet when we advise our members to do symptom based tapers?  We need to remain functional so tapers must be adjusted to achieve this, having a spreadsheet doesn't mean anything when we need to vary from it in order to be successful.

 

Here is a spreadsheet you can fill out for yourself if you wish, I would offer to help you do it but I don't know how.  http://benzo.alwaysdata.net/       

 

 

I think I'd ask for 2 or 3 week supplies of each dose instead of cutting each week.  I also think you could get doses reduced by 0.125 instead of 0.250.  That would make the cuts a little easier.  Things you can discuss with your doc or pharmacist.  A good pharmacist can make any dose needed, fwiw.

 

I agree that you don't want to take those capsules apart and make liquid out of them.  Just seems wasteful to me. 

 

Do what you can to create calm in and around you.  Don't absorb anybody's sh__.  You're teflon - it just bounces off.  Calm blue ocean.....