Can temazepam (Restoril) 15mg be taken concurrently with clonazepam (Klonopin) 1mg?

Concurrent Use of Temazepam and Clonazepam

Temazepam 15mg should not be taken concurrently with clonazepam 1mg due to the significantly increased risk of respiratory depression, central nervous system depression, and potentially fatal overdose. 1

Risks of Benzodiazepine Combination

The concurrent use of multiple benzodiazepines poses serious safety concerns:

• The CDC guidelines explicitly warn against co-prescribing benzodiazepines due to their additive central nervous system depressant effects 1
• Epidemiologic evidence shows concurrent benzodiazepine use in a large proportion of opioid-related overdose deaths 1
• A case-cohort study found that concurrent benzodiazepine prescriptions were associated with nearly quadrupled risk for overdose death compared to single benzodiazepine use 1

Pharmacological Considerations

Both medications have overlapping mechanisms and effects:

• Temazepam (15mg) is a medium-duration benzodiazepine primarily used for sleep maintenance insomnia 2, 3
• Clonazepam (1mg) is a long-acting benzodiazepine with anxiolytic, anticonvulsant, and sedative properties
• The combination creates additive sedation, respiratory depression, and cognitive impairment 1

Alternative Management Approaches

If a patient is currently taking clonazepam for anxiety and has insomnia:

1. First-line approach: Implement cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene practices 2

2. If medication is necessary:

   • Consider non-benzodiazepine options for insomnia such as:
     • Ramelteon 8mg for sleep onset insomnia 2
     • Low-dose doxepin (3-6mg) for sleep maintenance 2
     • Suvorexant for sleep maintenance issues 2

3. If benzodiazepine therapy is required:

   • Use only one benzodiazepine at the lowest effective dose
   • For patients already on clonazepam, consider adjusting the timing of the dose to help with sleep rather than adding temazepam
   • If switching medications is necessary, implement a gradual taper of one medication before introducing another 1

Special Considerations

• Elderly patients are at particularly high risk for adverse effects from benzodiazepine combinations, including falls, cognitive impairment, and respiratory depression 1, 4
• Patients with respiratory conditions such as COPD or sleep apnea face heightened risks from multiple benzodiazepines 2
• Monitor for signs of sedation, confusion, ataxia, and respiratory depression if benzodiazepines must be used 1

Clinical Pitfalls to Avoid

• Never abruptly discontinue either benzodiazepine as this can precipitate withdrawal symptoms including rebound anxiety, hallucinations, seizures, and in rare cases, death 1
• If tapering is necessary, reduce benzodiazepine dose by approximately 25% every 1-2 weeks 1
• Do not substitute with other CNS depressants (such as muscle relaxants or hypnotics) as these can also potentiate adverse effects 1
• Avoid dismissing patients from care based solely on their medication use patterns, as this can lead to patient abandonment and missed opportunities for treatment 1

In conclusion, while individual benzodiazepines may be appropriate in specific clinical scenarios, their concurrent use significantly increases risk without providing additional therapeutic benefit.