Author Topic: Valium 5mg titration - dry or liquid micro taper?  (Read 2729 times)

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #30 on: April 24, 2022, 07:28:03 pm »
Yes, I will return the 5mL syringes and have instead ordered 10mL syringes.
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[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #31 on: April 27, 2022, 09:28:58 pm »
Unfortunately, the adapter caps that I have received do not fit my vial of Valium. Because of my cognitive impairment, I don’t want to use the drop adapter as I will lose my focus while I count the drops and miscount.

I have thought of a simpler protocol to dilute the entire 20mL vial from 1% (10mg / mL) to 0.1% (1mg / mL) by adding 180mL distilled water. This only needs to be repeated once every few weeks.

Warning: DO NOT follow this protocol, see [...]’ post below — the diluted solution cannot be kept for longer than a few days.

Equipment:
- 100mL graduated cylinder
- 8oz low profile mason jar with a wide mouth (to facilitate drawing from it with a syringe)
- Deionized or distilled water
- 10mL syringe
- 1mL syringe
- Brush to wash the graduated cylinder
- Drying rack for the graduated cylinder (DYI)
- Optional: acetone or alcohol

Note: I do not have a 200mL or 250mL graduated cylinder so I am using a 100mL graduated cylinder here (tolerance +/- 0.5mL).

Cleaning the equipment:

1. Wash the mason jar and the graduated cylinder with warm tap water and soap or detergent. Use the brush to clean the inside of the cylinder without scraping it against the glass.
2. Rinse the inside and the outside of the mason jar and of the graduated cylinder with distilled water 3 to 4 times (to avoid residues from forming when drying).
3. (Optional.) To speed air drying, rinse the mason jar and the graduated cylinder with acetone or alcohol.
4. Hang the graduated cylinder upside down (by the base) on the drying rack.
5. Allow the mason jar and the graduated cylinder to air dry completely.

Sources:
- https://www.txstate.edu/chemistry/student-resources/Stockroom/cleaning-laboratory-glassware.html
- https://www.sigmaaldrich.com/EN/us/technical-documents/protocol/chemistry-and-synthesis/reaction-design-and-optimization/cleaning-glassware

Diluting the solution of Valium:

1. Measure 100mL distilled water with the graduated cylinder.
2. Pour the distilled water in the mason jar.
3. Measure 80mL distilled water.
4. Pour 60mL distilled water into the mason jar.
5. Pour the entire 20mL vial of Valium into the jar.
6. Rinse the vial:
- 6.1: Carefully pour 10mL distilled water into the vial.
- 6.2: Close the vial with its (leakproof) lid and shake.
- 6.3: Pour the content of the vial into the mason jar.
- 6.4: Repeat steps 6.1 to 6.3 once (i.e. with the remaining 10mL water).
7. Close the mason jar with its leakproof lid and shake.
8. Wait a few seconds, open the lid, tap it lightly vertically against the mason jar so that the remaining liquid on the underside falls into the jar.

Measure/ingest method, with an example of 7.5mg diazepam:

1. Repeat steps 7 and 8 above.
2. Measure 7mL diluted solution with a 10mL syringe, ingest.
3. Measure 0.5mL diluted solution with a 1mL syringe, ingest.

Finally, to taper by decrements of 0.1mg, simply draw 0.1mL less than the previous amount of diluted solution. (One can even decrement by smaller steps, depending on the graduations of their 1mL syringes.)

Of course, the mason jar needs to be stored away from light as it is not amber colored. One should ideally use a 8oz amber glass bottle with a fitting adapter cap for syringes.

As with the previous protocol, one issue is that it becomes a bit difficult to draw the last few milliliters of diluted solution from the mason jar with a syringe. (Tilting it slightly in a secure way helps, though.)

Other than that, is there anything wrong with this protocol?

(Side note: the graduated cylinder could even be replaced by a 0.01g precision scale. These scales usually have a weight limit, so one would need to use a lightweight beaker or a spouted cup, but they can measure the 180mL distilled water fairly accurately.)
« Last Edit: April 28, 2022, 05:11:45 pm by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #32 on: April 27, 2022, 11:03:32 pm »
This is your taper so it’s your call.  However, I personally would not risk this.  We simply do not know the ‘shelf-life’ (potency and stability over time) of homebrew liquids such as the one you are contemplating.  To our knowledge, none of these liquids has been professionally analyzed.

What we do know is that the U.S. Pharmacopeia gives a BUD (Beyond Use Date) of 14 days maximum for non-preserved aqueous Compounded Nonsterile Preparations (CNSPs). Per USP:

Quote
BUDs help decrease the risks that may be posed to patients. A CSP [Compounded Sterile Preparation] and CNSP’s BUD identifies the time by which the preparation – once mixed – must be used before it is at risk for physical or chemical degradation, microbial contamination and proliferation, and impact on the integrity of the container-closure system. In other words, the BUD serves to alert healthcare workers to the time/ day after which a CSP or CNSP must not be used.

We also know that Surviving Antidepressants recommends a 5-day maximum for storing/using homebrew liquids. 

Worst case scenario … what would happen if you use your entire medication supply to make a batch of homebrew liquid and it does not work for you?

Link:
USP Compounding Standards and Beyond-Use Dates (BUDs)
https://www.usp.org/sites/default/files/usp/document/our-work/compounding/usp-bud-factsheet.pdf

 
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #33 on: April 28, 2022, 11:19:20 am »
Agh, I was not aware of this but it makes sense. Thank you [...]. I won’t risk it, then. I will count the droplets as carefully as I can instead.

It is annoying that using oral syringes for medication is not a common practice in my (European) country as it is in the US. Non-intravenous medication here comes either in pills, vials with droplet adapters, or vials with caps for needle syringes (intramuscular injections).

Adapter caps seem to be made only in the US so it can’t be known in advance whether they will fit a certain European vial, even when having the measurements of the vial mouth and of the adapter cap. It is a trial and error process. (Also, only one small company in my country imports adapter caps from the brand Health Care Logistics.)
« Last Edit: April 28, 2022, 12:21:48 pm by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #34 on: April 28, 2022, 02:56:46 pm »
I am relieved you are not going to take the risk, [...].

You’d want to do a pro/con analysis of the following, but here are some options for your consideration:

- transfer the oral solution into a different container that is more ‘syringe friendly’ (e.g. wide enough mouth, glass, leak-proof top)

- make smaller batches (e.g. at your present dose of 7.5mg a day, you could make a 4-day batch using 3mL of your 10mg/mL oral solution in 297mL of water)

- use a combination of regular tablets and liquid
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #35 on: April 28, 2022, 05:15:08 pm »
Thank you for these ideas. I might transfer the solution to a smaller syringe-friendly glass recipient and keep it away from light, that seems to be the easiest solution for me.

For future readers, I have edited my previous post to mention your warning about the shelf life of the diluted solution.
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #36 on: April 28, 2022, 08:44:25 pm »
Well, I have trained myself to use a 1mL syringe by drawing too much water and pressing to draw it out. It takes some fine thumb control to slowly glide the plunger down 0.01mL by 0.01mL! I’ll continue training until I master this skill. I also need to train myself to draw just the right amount.

Edit: drawing/pulling is much easier than pressing the excess solution out.

[...], given that my 1mL syringes have 0.01mL graduations, may I ask why I cannot draw directly the amount required from the vial (e.g. 7.3mg would be 0.73mL)? Are the graduations too unreliable/inaccurate? They are tuberculin syringes without needles (Nipro brand).
« Last Edit: April 28, 2022, 09:28:06 pm by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #37 on: April 28, 2022, 11:14:31 pm »
The fact that your syringe has markings every 0.01mL does not mean you can accurately measure to that amount, especially if you are measuring a highly concentrated liquid such as your 10mg/1mL oral diazepam solution.

If you are interested in learning more about this topic, I’ve included a link to a blog post by a PharmD titled the illusion of accuracy.  If you’re short on time, read the section titled Syringe Accuracy; then skip to the final section titled So where does that leave us.

PS Thank you for helping to educate future readers about what we know/don’t know about the potency and stability of homebrew liquids.

Link:
the illusion of accuracy
https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy
« Last Edit: April 29, 2022, 12:28:42 am by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #38 on: April 29, 2022, 06:30:02 am »
Thank you for providing me these informative resources. I suspected such shenanigans. The part on the tolerance stack is interesting and was one of my concerns.

The loss of accuracy as the volume measured goes down in a 1mL syringe is much more significant than I expected. I understand from the article that it is preferable to measure 0.5mL or above to remain in a +/- 5% accuracy range instead of falling down to +/- 10% (or +/- 16% under 0.1mL). So I will always have to draw at least 0.5mL from the vial (0.5mg diazepam) — i.e. prepare at least 50mL of diluted solution — to ensure acceptable accuracy.

That said, despite the ISO norm for syringes, I suppose the accuracy range does not suddenly jump from +/- 5% at 0.5mL and above to +/- 10% under 0.5mL — it should be more like a gradient? That would mean we are probably close to +/- 10% accuracy at 0.5mL. This is making me wonder about the accuracy of the droplet adapter supplied by the manufacturer, too.

I also realize now that when preparing between 51mL and 89mL of diluted solution, the +/- 10% accuracy range of the 1mL syringe accuracy between 0.1 and 0.5mL will interfere with the measurement of the distilled water. For instance, to prepare 75mL, I need to draw 0.25mL distilled water so I would be drawing anywhere between 0.22 to 0.28mL water due to the error of ~0.03mL (rounded up to keep two significant numbers). This is fairly minimal and falls well within the +/- 0.5mL tolerance of the 100mL graduated cylinder (which is an order of magnitude greater). Is this a concern?

Anyhow, I think my prescriber should agree to prescribing me 5mg diazepam (15 drops) even as I reduce my dose below 5mg, so I won’t run out because I have to prepare solution in excess then. I just have to hope there won’t be more shortages of the oral prescription solution coming because of the manufacturer.

Edit: I have added a warning to one of my previous posts to reflect this information. http://www.benzobuddies.org/forum/index.php?topic=267260.msg3368491#msg3368491
« Last Edit: April 29, 2022, 09:37:53 pm by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.

[Buddie]

Re: Valium 5mg titration - dry or liquid micro taper?
« Reply #39 on: May 07, 2022, 10:56:36 pm »
If the diluted solution is prepared in advance the same day, how long can it be stored out of the fridge, if at all? Would anywhere between 1 to 6 hour(s) be OK, or is it too risky?
« Last Edit: May 07, 2022, 11:06:22 pm by [Buddie] »
Suggestions, opinions and/or advice provided by the author of this post should not be regarded as medical advice; nor should it substitute for professional medical care. Consult your doctor before making any changes to your medication. Please read our Community Policy Documents board for further information.