Valium Crossover Substitution Taper

[[Buddie]]

Hello again, [...].

Thank you for your kind words of appreciation. 

[...] has done an excellent job of explaining the rationale for tapering a short-acting benzodiazepine such as Ativan/lorazepam before a longer-acting benzodiazepine such as Klonopin/clonazepam.

Indeed, this causes me to wonder if you have considered substituting Klonopin for the Ativan and then doing a gradual, symptom-based taper from the Klonopin?

It would also be helpful if you could tell us more about how you ended up on two benzodiazepines.  Are you getting them from the same prescriber?  (If you are, I would be surprised if the same prescriber would be willing to prescribe a third benzodiazepine — Valium — to do a crossover.)

[[Buddie]]

[...]: 
Two different prescribers originally prescribed the benzos.  In Oct. 2020, I sought out a psychiatrist to help me get off them.  I was in such a state of extreme anxiety/panic that she had me take them every day until I stabilized.  I still haven’t stabilized, so in Sept 2021, I figured if I had anxiety even while taking them, that I might as well start somewhere & start getting off of them.

I have wondered if I could be switched from Ativan over to Klonopin so I’m just on one benzo.

[[Buddie]]

Thank you for the additional information, [...]. 

Am I understanding correctly that the psychiatrist you sought out to help you with discontinuation is now prescribing both the Ativan and the Klonopin?

If so, then my guess is she would be more receptive to replacing the Ativan with Klonopin and then tapering from Klonopin versus doing two crossovers to a third benzodiazepine (e.g., from Ativan to Valium and then Klonopin to Valium).

Is this something you’d like to consider?  If so, we can suggest a plan (or plans) on how this might be accomplished.

Would you be open to the idea of using a professionally formulated, stability-tested compounded clonazepam oral suspension to taper instead of the homebrew liquid you made with the clonazepam ODTs, propylene glycol, and water?  We suspect there are issues with the ‘recipe’ you used.

[[Buddie]]

Yes, [...], the psychiatrist I sought out is now prescribing both.

I’m hoping she will be open to my switching Ativan to klonopin.  One less drug would be nice even though they’d be comparable strength.  I’d totally be interested in that.

I am open to compounding.  I’d asked her about that initially & really didn’t feel like I got much interest from her.  She didn’t really have any solid advice or guidance on tapering, hence my home brew.  I wasn’t sure what else to do.

I don’t know if she’ll let me do anything until I restabilize some.  I’m not sure why I’m not restabilizing.  I really hope I get an appetite back soon & my heart/chest stops hurting (cleared by cardiologist.  Not actual heart issue).

I appreciate you 🙏🏻

[[Buddie]]

I'm pleased to see you open to crossing your Ativan dose to Clonazepam but I wanted to give you this cool little tool for determining the correct dose to cross to so you and your doctor can be on the same page for what you're going to need. https://clincalc.com/Benzodiazepine/

Also I feel it's an excellent idea to pursue compounded Clonazepam, I know [...] has been using one and as you can see, she's very high functioning. 

[[Buddie]]

Your CNS has been through a shock. It may take a while for things to settle down so please try to be patient (I know this is easier said than done).  Are you keeping a daily journal of your symptoms and level of functioning?  If not, I encourage you to do so.  Keeping a journal will allow you to see patterns and trends that can be easily missed in the absence of a written record of some sort.

That’s great that you are open to compounding.  It sounds like your psychiatrist may not have much experience with it.  My prescriber didn’t either but was willing to learn so I volunteered to find out what we would need to do, including finding a reputable compounding pharmacist with the expertise and equipment required to prepare the compound. I can share the process I used if you are interested.

If you have not already done so, I encourage you to explore the calculator [...] shared with you and consider sharing it with your prescriber at an appropriate moment.  The information in the ‘About this Calculator’ section can be quite helpful to both prescribers and patients.

[[Buddie]]

I do keep record of the symptoms as they’re a bit hard to figure out.

Question, when you crossover to Valium, you have to do a step-wise cross.  If I went from 0.5 Ativan & moved that to the equivalent klonopin dose of .25, do you have to do it step-wise as well?  Or just one day switch from Ativan to a new Klonopin dose of 0.5?

I would love any compounding information you have.  There are 2 compounding pharmacies in town that probably have the capabilities.

I’m assuming I need to wait until my CNS hopefully calms down some before attempting to taper again?  You would have thought I’d cold turkeyed it, the way my body reacted to the reduction.

[[Buddie]]

Good for you for keeping a record of your symptoms.  Do you also track your functionality?  If you are not already doing so, you might want to assign daily ratings to both your symptoms and your functionality. For example, on a scale of 0-10, how tolerable were your symptoms for that day?  On a scale of 0-10, how functional were you on that day?  Graphing such daily ratings would allow you to see patterns and trends.

In your case, my inclination would be to adopt a conservative approach to a lorazepam to clonazepam crossover.  What is the dosage of the lorazepam tablets you are taking?  0.5mg?  If so, one possible approach would be to split the tablet in half to get a dose of 0.25mg.  Then you could do a two stage crossover as follows:

Stage 1
0.25 clonazepam ODT + 0.125 clonazepam ODT + 0.25mg lorazepam

Hold at the above doses for 10-14 days to give the clonazepam sufficient time to reach steady state.  You may experience an uptick in withdrawal symptoms over the first week as the lorazepam is eliminated from your body.

Pay close attention to how you react to the above change to gauge: (1) if the substituted dose of clonazepam is too much, too little, or about right (e.g. some individuals discover that the Ashton equivalent is higher than they need to achieve the desired therapeutic effect) and (2) how you react to the change.

If your symptoms stabilize (i.e. stop changing, become tolerable) after Stage 1, you could proceed to Stage 2.

Stage 2
0.25mg clonazepam ODT + 0.125 clonazepam ODT + 0.125mg clonazepam ODT

Needless to say, you would be wise to discuss all of the above with a pharmacist who understands the pharmacokinetics of benzodiazepines.

That’s excellent news that you have not one but two compounding pharmacies in your town.  Do they specialize in compounding or are they ‘regular’ pharmacies that do compounding ‘on the side’?  The former is preferable to the latter.   If the pharmacies specialize in compounding, a first step you could take is to find out (a) if they are accredited (e.g. PCAB) and (b) what professional associations they belong to (e.g. PCCA).  I will also work on a consolidated list of what to look for and questions to ask when vetting a compounding pharmacy.

Your assumption is correct.

[[Buddie]]

The compounding pharmacies are true compounding pharmacies.  I think one is a national chain, College Pharmacy.

I have 0.5 mg tablets of lorazepam.

Are you recommending taking them 3x a day?  With lorazepam being the evening dose in Stage 1?

Thank you for your help 🙏🏻

[[Buddie]]

You’re welcome!

Thank you for the confirm re: your tablet dosage.

No, I was not recommending you take them 3x a day.  I was just suggesting one way you could do the crossover using a combination of tablets.  My assumption was that you would take them at the same time you currently take your meds (i.e. at night).

Are you considering changing your dosing schedule?   If so, why?

I’ll check out College Pharmacy.