Which is favored for sleep issues: Clonazepam (Klonopin) or Lorazepam (Ativan)?

From the Guidelines

Neither clonazepam 0.5mg nor lorazepam 1mg tablets are generally favored as first-line treatments for sleep issues. While both medications are benzodiazepines that can help with sleep, they are typically recommended only for short-term use (2-4 weeks maximum) due to risks of dependence, tolerance, and withdrawal symptoms, as noted in a 2020 study 1. For insomnia, non-benzodiazepine sleep medications (like zolpidem or eszopiclone) or cognitive behavioral therapy for insomnia (CBT-I) are usually preferred first.

Key Considerations

• The work group advised against use of benzodiazepines or trazodone for treatment of chronic insomnia disorder, as stated in a 2020 study 1.
• If a benzodiazepine must be used, lorazepam 1mg might be slightly preferred for sleep issues specifically because it has a shorter half-life (10-20 hours) compared to clonazepam (30-40 hours), making it less likely to cause daytime drowsiness.
• However, this choice should always be made by a healthcare provider based on individual patient factors, including the specific type of sleep problem, other medications being taken, and any history of substance use disorders.
• A more recent study from 2023 1 also supports the use of alternative treatments, such as melatonin, for sleep issues.

Important Side Effects

• These medications should be taken only as prescribed, typically 30 minutes before bedtime, and patients should be aware of potential side effects including morning grogginess, dizziness, and impaired coordination.
• Clonazepam can also exacerbate sleep-disordered breathing, as noted in a 2023 study 1.
• The choice of medication should be based on the patient's underlying disease and attendant symptoms, as well as the potential risks and benefits of each medication, as discussed in a 2023 study 1.

From the FDA Drug Label

For insomnia due to anxiety or transient situational stress, a single daily dose of 2 mg to 4 mg may be given, usually at bedtime. The usual range is 2 mg/day to 6 mg/day given in divided doses, the largest dose being taken before bedtime, but the daily dosage may vary from 1 mg/day to 10 mg/day

Lorazepam 1mg tablets are favored for sleep issues, as the dosage for insomnia is explicitly stated as 2 mg to 4 mg, usually at bedtime 2. Clonazepam 0.5mg tablets do not have explicit dosage information for sleep issues in the provided label 3.

From the Research

Comparison of CLONAZEPAM and LORAZEPAM for Sleep Issues

• CLONAZEPAM 0.5MG TABLETS have been evaluated in several studies for their efficacy in treating sleep disorders, including insomnia and REM sleep behavior disorder 4, 5, 6.
• In a sleep laboratory study, CLONAZEPAM 0.5 mg was found to produce a significant decrease in total wake time initially and with continued administration 4.
• LORAZEPAM 1MG TABLETS have not been directly compared to CLONAZEPAM 0.5MG TABLETS in the provided studies, but CLONAZEPAM 1 mg has been compared to low-dose CLONAZEPAM with cognitive behavioral therapy in older adults with moderately severe insomnia 6.
• A prospective cohort study found that high-dose CLONAZEPAM (1 mg) was not more effective than low-dose CLONAZEPAM (0.5 mg) with cognitive behavioral therapy in improving sleep quality in older adults with moderately severe insomnia 6.
• Another study compared the safety and efficacy of melatonin, CLONAZEPAM, and trazodone in patients with Parkinson's disease and sleep disorders, and found that all three treatments were effective in improving sleep quality, but with different effects on sleep architecture 7.

Efficacy of CLONAZEPAM for Sleep Disorders

• CLONAZEPAM has been found to be effective in reducing total wake time and improving sleep quality in patients with insomnia and REM sleep behavior disorder 4, 5.
• However, CLONAZEPAM can cause rebound insomnia and anxiety, particularly with later withdrawal 4.
• The use of CLONAZEPAM in combination with other treatments, such as cognitive behavioral therapy, may be a viable alternative to increasing the dose of CLONAZEPAM 6, 8.

Comparison with Other Treatments

• Melatonin has been found to impact sleep architecture more than CLONAZEPAM, with a significant increase in N3 stage and moderate reduction in N2 and REM sleep 5.
• Trazodone has been found to be effective in improving sleep quality in patients with Parkinson's disease and sleep disorders, with a higher decrease in Epworth Sleepiness Scale score compared to CLONAZEPAM 7.
• Cognitive behavioral therapy has been found to be effective in improving sleep quality in patients with insomnia and periodic limb movement disorder, with contrasting effects compared to CLONAZEPAM 8.