RIVOTRIL AT-HOME WITHDRAWAL AND TAPERING PROGRAM

Rivotril is a benzodiazepine that has muscle relaxant, sedative, anticonvulsant and hypnotic properties. Rivotril is considered a ‘highly potent’ benzodiazepine with a rapid onset of action meaning that it reaches peak blood levels in one to four hours after oral administration, but leaves the body in 18-60 hours.

One-third of Rivotril patients will develop tolerance to the drug in 2-4 weeks and will suffer from the Benzodiazepine Withdrawal Syndrome, a grouping of extremely painful symptoms that can last many months. Even after short-term use (7-14 days) Rivotril can prove to be too challenging to just stop, therefore a slow taper is recommended.

Klonopin (Rivotril) was brought to market in 1975 for the treatment of epilepsy. Dr. Leo Sternbach, an award winning chemist, helped the Swiss drug conglomerate Roche Pharmaceutical build its U.S. division, after fleeing Europe when the Nazis were threatening to invade Europe in 1941. Sternbach went on to patent 241 drugs, including Valium, and accounted for 40% of Roche's worldwide sales. The use of Klonopin (Rivotril) expanded beyond epilepsy and was used for anxiety, insomnia, muscle tension and many other ailments.

Rivotril enhances the neurotransmitter GABA, which is the most common inhibitory, or calming neurotransmitter. Therefore Rivotril has a profound effect on nearly every aspect of the body and brain. As tolerance to the drug occurs, the calming effect diminishes and breakthrough anxiety and extreme excitability occurs. Many misinterpret tolerance for a worsening of anxiety and increase the dosage, only to reach tolerance again. Chronic use of Rivotril, like all benzodiazepines, causes a down regulation of GABA. It is this action that is responsible for the widespread withdrawal symptoms.

Tolerance to Rivotril's anticonvulsant effect occurs frequently and chronic use leads to tolerance for the anti-anxiety properties. One milligram of Rivotril is approximately equivalent to twenty milligrams of Diazepam (Valium), making Klonopin a 'highly potent' benzodiazepine.

Abrupt withdrawal of Rivotril can cause seizures, severe withdrawal symptoms and be life-threatening. A gradual dose reduction is recommended.

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RIVOTRIL WITHDRAWAL SYMPTOMS MAY INCLUDE:

aggression, anxiety, balance issues , blurred vision, brain zaps, concentration impairment, constipation, crying spells, depersonalization, diarrhea, dizziness. electric shock sensations, fatigue, flatulence, flu-like symptoms, hallucinations, hostility, highly emotional, indigestion, irritability, impaired speech, insomnia, jumpy nerves, lack of coordination, lethargy, migraine headaches / increased headaches, nausea, nervousness, over-reacting to situations, paranoia, repetitive thoughts or songs, sensory & sleep disturbances, severe internal restlessness (akathisia), stomach cramps, tremors, tinnitus (ear ringing or buzzing), tingling sensations, troubling thoughts, visual hallucinations / illusions, vivid dreams, speech or visual changes, worsened depression, insomnia, abdominal and muscle cramps, convulsions, feeling of discomfort, inability to fall asleep or stay asleep, sweating, tremors, vomiting 

 RIVOTRIL SIDE EFFECTS MAY INCLUDE: 

daytime drowsiness, amnesia or forgetfulness, memory impairment, muscle weakness, lack of balance or coordination, cognitive issues, tiredness, changes in appetite, nausea, diarrhea ,stomach upset, headache, muscle pain, confusion, insomnia, visual changes, memory loss, difficulty concentrating, confusion, hallucinations, slurred speech, agitation, aggressive behavior, anxiety, loss interest in sex, fatigue, nervousness, worsening depression

 RIVOTRIL ADVERSE REACTIONS MAY INCLUDE: per PDR 

 Severe: suicidal ideation, coma, teratogenesis, visual impairment 

Moderate: ataxia, depresion, memory impairment, constipation, dysarthria, vaginitis, impotence, blurred vision, confusion, migraine, paresis, excitability, hemorrhoids, candidiasis, dyspnea, urinary incontinence, dysuria, urinary retention, bleeding, cystitis, hypertonia, contact dermatitis, orthostatic hypotension, edema, chest pain, palpitations, gout, tolerance, physiological dependence, psychological dependence, amnesia, hallucinations, hostility, psychosis, fecal incontinence, gastritis, withdrawal, respiratory depression, lymphadenopathy, hypotonia, nystagmus, thombocytopenia, anemia, eosinophilia, elevated hepatic enzymes, leukopenia, hepatomegaly, dehydration 

Mild: drowsiness, dizziness, infection, fatigue, sinusitis, dysmenorrhea, influenza, rhinitis, cough, myalgia, anorexia, pharyngitis, libido decrease, emotional lability, abdominal pain, increased urinary frequency, vertigo, hypoesthesia, tremor, paresthesias, shivering, anxiety, insomnia, nightmares, yawning, dyspepsia, weight gain, flatulence, dysgeusia, pyrosis, weight loss, appetite stimulation, hyper salivation, fever, epistaxis, hoarseness, sneezing, libido increase, menstrual irregularity, urine discoloration, polyuria, back pain, musculoskeletal pain, muscle cramps, arthralgia, diplopia, xerophthalmia, alopecia, flushing, pruritus, acne vulgaris, headache, agitation, irritability, nausea, diarrhea, rhinorrhea, nocturia, weakness, rash, hirsutism  

 RIVOTRIL  BOXED WARNINGS:  per PDR

Asthma, bronchitis, chronic obstructive pulmonary disease (COPD), CNS depression, coadministration with other CNS depressants, coma, pulmonary disease, respiratory depression, shock, sleep apnea 

As with other benzodiazepines, clonazepam should be used with extreme caution in patients with pulmonary disease or conditions associated with compromised respiratory function such as sleep apnea, bronchitis, pneumonia, asthma, or chronic obstructive pulmonary disease (COPD). Additionally, avoid coadministration with other CNS depressants, especially opioids, unless no other alternatives are available as coadministration significantly increases the risk for respiratory depression, low blood pressure, and death. If coadministration is necessary, follow patients for signs and symptoms of respiratory depression and sedation. Clonazepam should not be used in patients with preexisting respiratory depression, cases of shock, or coma because the drug can worsen respiratory and CNS depression. In patients who snore regularly, partial airway obstruction may convert to obstructive sleep apnea with benzodiazepine administration. Clonazepam may produce hypersalivation and may aggravate conditions in which patients have difficulty handling secretions. 

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According to the FDA:

Withdrawal Symptoms: Withdrawal symptoms of the barbiturate type have occurred after the discontinuation of benzodiazepines (see DRUG ABUSE AND DEPENDENCE).

PRECAUTION

General: Worsening of Seizures: When used in patients in whom several different types of seizure disorders coexist, Klonopin (Rivotril) may increase the incidence or precipitate the onset of generalized tonic-clonic seizures (grand mal). This may require the addition of appropriate anticonvulsants or an increase in their dosages. The concomitant use of valproic acid and Klonopin (Rivotril) may produce absence status.

Laboratory Testing During Long-Term Therapy: Periodic blood counts and liver function tests are advisable during long-term therapy with Klonopin (Rivotril).

Risks of Abrupt Withdrawal: The abrupt withdrawal of Klonopin (Rivotril), particularly in those patients on long-term, high-dose therapy, may precipitate status epilepticus. Therefore, when discontinuing Klonopin (Rivotril), gradual withdrawal is essential. While Klonopin (Rivotril) is being gradually withdrawn, the simultaneous substitution of another anticonvulsant may be indicated. 

 REFERENCES:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017533s053,020813s009lbl.pdf

https://www.ncbi.nlm.nih.gov/pubmed/20473065

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934057/

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