Using a Manufacturer’s Oral Liquid

1. Identify the ratio of active drug to liquid.

Manufacturers’ oral liquids come in a concentration of drug amount (in mg) to liquid volume (in mL). For example, a manufacturer’s liquid may say 25mg/5mL, which would mean 25mg of active drug per 5mL of liquid. It’s essential to identify exactly how much active drug is in a given volume of the liquid, since the accuracy of taper calculations depends on it. This information should be in the drug label (see Step 10 for more information) and provided by the pharmacist.

2. Identify any differences in potency.

The body processes liquid drugs differently than it does solid drugs – this can sometimes mean that different forms of the same active drug at the same dose level can actually differ from each other in potency. If switching from solid to liquid, it is vital to identify whether this is the case for any manufacturer’s oral liquid that may be taken and/or tapered off. This information should be in the drug label and is best confirmed by a well-informed pharmacist. By way of example: The ‘Dosage and Administration’ section of the FDA-approved drug label for Abilify (aripiprazole) states that a 25mg dose of the manufacturer’s oral solution is essentially equal to a 30mg dose tablet.

3. Determine what kind of manufacturer’s liquid you are taking, whether it is safe to further dilute, and what liquid to use for the dilution.

Given the tiny cuts in daily dose that are required when using a Daily Microtaper schedule, and the tiny daily doses that people are eventually taking when they get towards the end of the taper journey with either a Daily Microtaper or Cut-and-hold schedule, it’s necessary for a drug to be suspended or dissolved in a large-enough volume of liquid that such small, incremental amounts are possible to remove for each dose. This often requires further diluting each dose of a manufacturer’s liquid.

The three common liquids that psychiatric drugs are available from a manufacturer as are “oral solution”, “oral suspension”, or “oral concentrate”. A manufacturer’s oral concentrate is designed to be further diluted, and the drug label should explain how to do so (see Step 10 for help finding information in drug labels). There is likely to be no information in the drug label about further diluting an oral solution or oral suspension, so it is important to ask a well-informed pharmacist the following questions:

• Is it safe to dilute a dose of this oral solution/suspension?
   
• If so, by how much liquid can it be further diluted?
   
• What liquids are safe and unsafe to use to dilute a dose of this oral solution/suspension? (Ask about any possible pros and cons of different liquids.)
   

Some further measures to take:

• Investigate whether there are any possible risky interactions or incompatibilities between the drug and any particular liquids. Refer to Step 10 to find where this information may be in your drug label and consult a well-informed pharmacist. Always follow the instructions of the drug label for ensuring a manufacturer’s liquid is evenly distributed (for example, shaking or stirring immediately prior to removing a dose).
   
• Consult the drug label for general information about storing the drug and consult a well-informed pharmacist about how the drug, when further diluted, should be stored.

4. Record decisions.

If your drug is safe to further dilute, note the relevant information in your taper journal:

Maximum volume for dilution:
Length of time to store:
How to store:
Unsafe liquids for dilution:
Safe liquids for dilution:
Liquid I’ll use for dilution:
 

5. Set a schedule

Back in Step 14, you decided whether you’d taper using a Daily Microtaper or Cut-and-hold schedule. If it’s been a while since you made that decision, you might want to go back to that step and refresh your memory. As mentioned above, Daily Microtaper schedules typically require diluting a manufacturer’s liquid, and Cut-and-Hold schedules may eventually require the same. Some of the calculations you’ll do in Step 19 will also depend on your chosen schedule.

6. Read up on layperson tips for choosing the volume of liquid to use for a pharmacist-approved liquid dilution. (Skip if not diluting.)

Here are a few tips laypeople often share with one another to help inform the decision of how much liquid to use for a liquid dilution:
 

• Choose a volume that’s large enough to allow for accurate and more easily made small reductions in dose based on a particular schedule and taper rate. 
  As discussed above, generally speaking, the larger the volume of liquid that a solid is distributed in, the fewer particles of solid there will be in a particular portion of that liquid. Therefore, a general principle in using a liquid for tapering is that the more liquid there is, the smaller a reduction in dose one can make at any given time. This is particularly relevant for people who are doing a Daily Microtaper since, all other factors being equal, the amount removed each day is teeny-tiny in comparison with a Cut-and-hold schedule, where bigger cuts are made less frequently.
   
• Choose an amount that makes the measuring and math easier.
  To simplify the math calculations, some people opt for a liquid volume that will make it easy to remove cuts that fall cleanly into relatively simple numbers, given their chosen taper schedule and monthly taper rate. And of course it’s important to keep in mind that, when combining a manufacturer's oral liquid with a diluent liquid, the total starting amount for beginning to make calculations and cuts will be the amount of both liquids together in mL.. For more information, see 'Doing calculations for a Taper' and 'Special Tips for Calculations and Liquids' in Step 18.