Tapering serax

[Attending1985]

I inherited a patient on 15 mg qid and I’m trying to plan a taper. Anyone have experience with this. Was thinking of switching to diazepam then tapering.

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[Doc1401]

I inherited a patient on 15 mg qid and I’m trying to plan a taper. Anyone have experience with this. Was thinking of switching to diazepam then tapering.

There is no actual data to support switching to a long acting benzo as part of the taper process, despite it being a common practice.

 

[st2205]

There is no actual data to support switching to a long acting benzo as part of the taper process, despite it being a common practice.

I’ve found that it serves to piss people off.

 

[birchswing]

I don't think that's the type of research people are highly motivated to do.

But at a very pragmatic level, doesn't it make sense to switch to a medication that allows gradual reduction and that would lessen interdose withdrawal?

You can only cut a Xanax or Ativan etc. tablet in half so many times before it's a powdery mess, whereas Valium comes in the (theoretical) equivalent of 0.2 mg Ativan, which is scored to cut into a theoretical 0.1 mg Ativan.

Serax as a Valium metabolite is an odd exception where it's even less potent per mg than Valium.

But still it comes in a capsule form, which isn't ideal for tapering, unless the patient is doing a suspension taper (which is just a mess and pain). On the other hand, a compounding pharmacist could help with making smaller doses.

If you do a Valium crossover, I would advise looking at the UK NICE or Ashton guidelines and not switch over to diazepam all at once (they advise a step cross-taper). Since it's a metabolite maybe it's a different story, but with some of the other short-acting benzos you can't really predict what an equivalent dose is until you make a cross and you can end up making too steep of a cut or having them knocked out till next week. And if you make a substitution and it takes you out of tolerance withdrawal (the patient can tell--you feel normal again--probably from making a substitution that was on the generous side of the theoretical equivalence), in my experience making a cut (still gradual) as soon as possible is easier than waiting until that normal feeling fades.

 

[SilverHawk]

Tapering should put into consideration what other medical co-morbidities the patient has. For a slow taper, consider reducing dosage by 10% each week (or even every other week), monitor closely for symptoms. As mentioned above, no concrete data for switching to long acting benzos. However, I've found that it can be helpful to mitigate withdrawal symptoms (Librium I've used). As mentioned would look up benzo conversion charts if you plan to go that route. If really concerned for withdrawal or with a lot of medical issues on board, may need short inpatient montoring.

 

[whopper]

Bottom line: Can't be done in faster than 3 days, the faster you do it the higher the risk, the slower you do it the lower the risk but requires compliance from the patient.

If you want to do it slow and the patient is not very compliant it's going to be next to impossible if not impossible.

The faster than 3 days thing, if the patient is on a high dosage of benzos they are still at high risk for a seizure past 3 days but this is the minimum required time. I've seen patients have seizures from benzo withdrawal much longer than 3 days after being tapered off. if the patient is on a very high dosage I wouldn't use that 3 day rule.

 

[thoffen]

You're talking about a detox if you're saying 3 days. Much different and patient can still have significant withdrawal or even seizure beyond that time depending on half-life of BZD, etc.

Here I agree with sticking with the Serax for taper. Half life is about 8hrs and patient already taking it daily so having peaks/troughs they are used to already. Switching runs into questions of equivalence and difference in metabolism. More importantly, someone may feel much different on the new benzo, increasing risk of relapse or abuse.

I would consider detox if you can do it under adequate supervision if they have actual addiction. Outpatient tapers can be really hard on people who have to fight the reward pathway and patients may take extra, buy off the street, etc.

Edit: sorry I read qid as qd instead...

 

[Attending1985]

So serax is typically dosed qid and the smallest capsule I can get is 10 mg. The problem I think I’m gonna run into is dropping dosages once I get to 10 mg qid. Any thoughts?

 

[birchswing]

So serax is typically dosed qid and the smallest capsule I can get is 10 mg. The problem I think I’m gonna run into is dropping dosages once I get to 10 mg qid. Any thoughts?

Compounding pharmacy.

 

[Jules A]

So serax is typically dosed qid and the smallest capsule I can get is 10 mg. The problem I think I’m gonna run into is dropping dosages once I get to 10 mg qid. Any thoughts?

TID, unlikely they are actually taking at 6 hour intervals. Aren't there tabs?

 

[birchswing]

TID, unlikely they are actually taking at 6 hour intervals. Aren't there tabs?

I use this site all the time. Sometimes not all the data is 100% correct (or sometimes they list the name of a manufacturer that no longer exists because it's been bought by another outfit), but it's generally pretty good. Looks like almost all formulations have been discontinued including all tablets:

Drugs@FDA: FDA Approved Drug Products

(I can't provide a direct link but if you search for Oxazepam it will show all the available manufacturers and whether they've been discontinued or not. It's also a great site for newer drugs where you can see the the drug approval data the FDA assessed in how they came to approve a drug.)

Edit: Also if you search by brand name, it will list it separately rather than with the other generic manufacturers--so you have to check that separately. Looks like there is no brand name manufacturer in the US.

 

[Attending1985]

I use this site all the time. Sometimes not all the data is 100% correct (or sometimes they list the name of a manufacturer that no longer exists because it's been bought by another outfit), but it's generally pretty good. Looks like almost all formulations have been discontinued including all tablets:

Drugs@FDA: FDA Approved Drug Products

(I can't provide a direct link but if you search for Oxazepam it will show all the available manufacturers and whether they've been discontinued or not. It's also a great site for newer drugs where you can see the the drug approval data the FDA assessed in how they came to approve a drug.)

Edit: Also if you search by brand name, it will list it separately rather than with the other generic manufacturers--so you have to check that separately. Looks like there is no brand name manufacturer in the US.

Thanks for this. Maybe a good reason to transition to the long acting.

 

[birchswing]

Thanks for this. Maybe a good reason to transition to the long acting.

You can always check with a pharmacist. That site isn't always 100% perfectly up to date.

But I think some of the advice about staying on the same agent is good in that when you transition you are going on a different drug and the transition itself can be hard. But if you do transition, I definitely think there is merit in not crossing over all at once because the estimates are too imprecise and Valium in particular is very soporific--although I guess Serax as its metabolite is too. Your patient isn't on that high of a dose, so I still think a compounding pharmacy might be best.

Also, since you are possibly doing something for a patient based on something I said, I wanted to point out again that I am not a doctor. I think you know that because I kind of remember writing with you before. But I wanted to point that out again just so nobody takes any action believing the info came from anyone other than a lay person.

 

[Ceke2002]

Thanks for this. Maybe a good reason to transition to the long acting.

Aside from the physical benefits (of which admittedly I've forgotten most of, and Birch is far more up to date with) I think another positive with the idea of transitioning to long acting, and then tapering from there, is that for some patients it can be psychologically easier to do it that way if they've had a previous bad experience trying to just taper straight off the shorter acting medication. Speaking from a personal point of view I suspect this was a big part of why I was able to taper successfully off of a pretty stupidly high prescribed dosage of Xanax by doing the Ashton Method cross taper to long acting style treatment, whereas before I had only been able to taper down to a certain dosage of Xanax (4mgs a day) and then just got totally stuck. Previously I had tried to go cold turkey off a fairly long term dosage of around 8-12 mgs per day (with a maximum allowed dosage of 16-18mgs a day, and yes that was a level prescribed by a Doctor at the time) and not surprisingly I had a seizure by the second day after going into a psychotic episode on the first night. The experience scared me so much that even though I'd found a really good Doctor a couple of years later who helped me to at least reduce the dosage I was taking, I just could not get beyond a certain point because I'd start to completely freak out that I was going to have another seizure. When I transitioned over to Valium though, and then started tapering again from there, it was mentally different because if I did start to get panicky about seizures and stuff I could remind myself, or my Doctor could remind me herself that it was okay, I wasn't tapering off of Xanax this time, it was a different type of Benzo, I was safe, I wasn't going to have a seizure and the I could sort of relax and be like, "Okay, no seizures, that's good, I can get through this then". It might sound silly, but for me personally it was a hugely beneficial aspect of doing the 'Ashton Method'.