From the Guidelines
Clonazepam should be used with caution in patients with REM sleep behavior disorder (RBD), starting with a low dose of 0.25 mg at bedtime, due to its potential for dependence and side effects such as morning sedation, gait imbalance, and cognitive disturbances. According to the most recent guideline 1, clonazepam is one of the agents conditionally recommended for the treatment of secondary RBD, but its use should be carefully considered in the context of the patient's underlying disease and attendant symptoms. The guideline also notes that clonazepam can exacerbate sleep-disordered breathing and is listed on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications in older adults.
Some key points to consider when prescribing clonazepam for RBD include:
- Starting with a low dose of 0.25 mg at bedtime and gradually increasing as needed and tolerated
- Monitoring for side effects such as morning sedation, gait imbalance, and cognitive disturbances
- Being aware of the potential for dependence and the need for careful tapering when discontinuing the medication
- Considering alternative treatments, such as melatonin or rivastigmine, which may have a more favorable side effect profile in certain patients
It's also important to note that the guideline recommends a conditional recommendation against the use of deep brain stimulation (DBS) in the treatment of secondary RBD, and that other treatments, such as sodium oxybate for narcolepsy, may be considered in the appropriate clinical context. Overall, the use of clonazepam in RBD should be individualized and carefully monitored to minimize the risk of adverse effects and optimize treatment outcomes, as supported by the most recent evidence 1.
From the FDA Drug Label
Clonazepam tablets is a benzodiazepine medicine. Benzodiazepines can cause severe drowsiness, breathing problems (respiratory depression), coma, and death when taken with opioid medicines Clonazepam tablets can make you sleepy or dizzy and can slow your thinking and motor skills. Do not drive, operate heavy machinery, or do other dangerous activities until you know how clonazepam tablets affects you. Clonazepam tablets may cause problems with your coordination, especially when you are walking or picking things up Do not drink alcohol or take other drugs that may make you sleepy or dizzy while taking clonazepam tablets until you talk to your healthcare provider. The main concerns with Clonazepam are:
- Severe drowsiness and respiratory depression when taken with opioid medicines
- Sleepiness and dizziness
- Impaired coordination and motor skills
- Abuse and dependence It is essential to follow the healthcare provider's instructions and attend all scheduled follow-up visits to monitor for any adverse effects. 2
From the Research
Clonazepam Overview
- Clonazepam is a benzodiazepine that has been used to treat panic disorder with or without agoraphobia 3, 4.
- It has several advantages over other benzodiazepines and can be considered a first-line agent for panic disorder 3.
- Clonazepam has a relatively long half-life, which permits less frequent dosing and more continuous control of anxiety 4.
Efficacy and Safety
- Studies have shown that clonazepam is clinically effective in reducing the number of panic attacks 3, 4, 5.
- The minimum effective dosage of clonazepam is 1.0 mg daily, and daily dosages of 1.0 to 2.0 mg offer the best balance of therapeutic benefit and tolerability 5.
- Clonazepam is generally well tolerated, but common adverse effects include somnolence, ataxia, depression, dizziness, fatigue, and irritability 4, 5.
Discontinuation and Tapering
- Discontinuation of clonazepam can be challenging, but it can be safely tapered off with a gradual reduction in dosage 6, 5.
- A recommended tapering schedule is to reduce the dosage of clonazepam by 0.25 mg per week 6.
- Clonazepam discontinuation symptoms are mostly mild and include anxiety, shaking, nausea, insomnia, and headache 6.