Recommended Dose and Frequency of Clonazepam (Klonopin) for Adults
For adults with panic disorder, clonazepam should be initiated at 0.25 mg twice daily, with a target dose of 1 mg/day (0.5 mg twice daily), which can be increased to a maximum of 4 mg/day if needed. 1
Dosing Guidelines by Indication
Panic Disorder
- Initial dose: 0.25 mg twice daily
- Target dose: 1 mg/day (based on optimal efficacy with fewer side effects)
- Titration: Increase by 0.125-0.25 mg twice daily every 3 days as needed
- Maximum dose: 4 mg/day, although doses above 1 mg/day show diminishing returns with more side effects 1, 2
- Administration: Can be given as divided doses or with one dose at bedtime to reduce daytime somnolence 1
Seizure Disorders
- Initial dose: Should not exceed 1.5 mg/day divided into three doses
- Titration: Increase by 0.5-1 mg every 3 days until seizures are controlled
- Maximum dose: 20 mg/day
- Administration: Divided into three equal doses; if unequal, largest dose at bedtime 1
REM Sleep Behavior Disorder (RBD)
- Recommended dose: 0.5-2.0 mg taken 30 minutes before bedtime 3
- Starting dose: Often 0.25 mg with gradual titration
- Note: Older patients may be more sensitive to sedating side effects and take longer to metabolize clonazepam 3
Special Populations
Elderly Patients
- Start with lower doses and observe closely
- More susceptible to adverse effects including cognitive impairment, reduced mobility, and falls 4
- Longer elimination half-life in elderly patients
Patients with Hepatic Impairment
- Lower doses may be required due to decreased metabolism
- Closer monitoring for side effects is recommended
Administration Guidelines
- Take with water by swallowing the tablet whole 1
- For optimal effect in panic disorder, divide the daily dose into two administrations
- For sleep disorders, administer as a single dose 30 minutes before bedtime 3
Duration of Treatment
- No definitive evidence on optimal duration of treatment
- Physicians should periodically reevaluate the long-term usefulness for individual patients 1
- For long-term use, use the lowest effective dose for the shortest duration possible 4
Discontinuation
- Gradual tapering is essential to avoid withdrawal symptoms
- Recommended tapering: Decrease by 0.125 mg twice daily every 3 days 1
- Alternative tapering: Reduce dose by 25% every 1-2 weeks, or 0.25 mg per week for slower withdrawal 4
Common Side Effects
- Somnolence (most common)
- Ataxia
- Dizziness
- Cognitive impairment
- Fatigue
- Irritability 2
Efficacy Considerations
- For panic disorder, daily doses of 1.0-2.0 mg offer the best balance of therapeutic benefit and tolerability 2
- Response to treatment should be observed within 2-4 weeks 5
- For RBD, clonazepam has shown clinically significant improvements in symptoms 3
Clonazepam should be used cautiously due to risks of tolerance, addiction, and cognitive impairment, particularly with long-term use. Regular monitoring and periodic attempts at dose reduction are recommended to minimize these risks.