What is a reasonable dose of clonazepam (benzodiazepine) for 30 days to treat panic disorder?

Reasonable Dose of Clonazepam for Panic Disorder

For panic disorder, a reasonable 30-day treatment with clonazepam should start at 0.25 mg twice daily, with a target dose of 1 mg/day (divided into two doses), and should not exceed 4 mg/day. 1

Initial Dosing and Titration

• The FDA-approved initial dose for adults with panic disorder is 0.25 mg twice daily 1
• After 3 days, the dose may be increased to the target dose of 1 mg/day, which has been shown to be the optimal effective dose in clinical studies 1, 2
• Daily doses of 1.0-2.0 mg offer the best balance of therapeutic benefit and tolerability 2
• To reduce daytime somnolence, one dose may be administered at bedtime 1

Dose Range and Maximum Dose

• While the target dose is 1 mg/day, some patients may require up to 4 mg/day (maximum recommended dose) 1
• If needed, dose increases should be made in increments of 0.125 mg to 0.25 mg twice daily every 3 days until panic disorder is controlled or side effects become problematic 1
• In the original studies of clonazepam for panic disorder, the mean effective dose was approximately 1.9 mg/day 3

Important Considerations

• Higher doses (2,3, and 4 mg/day) have been shown to be less effective than 1 mg/day and are associated with more adverse effects 1
• Clonazepam is a long-acting benzodiazepine with an elimination half-life of 30-40 hours and is rapidly absorbed after oral administration 4
• Maximum plasma concentrations are reached within 1-4 hours after oral administration 4
• Studies have reported minimal dosage tolerance and medication abuse with clonazepam for management of panic disorder 4

Side Effects to Monitor

• The most common side effect is somnolence 2
• Other potential side effects include:
  • Morning sedation 4
  • Ataxia (particularly at higher doses of 3-4 mg/day) 2
  • Dizziness, fatigue, and irritability 2
  • Memory dysfunction 4
  • Risk of falls, particularly in elderly patients 4
• Clonazepam at 0.5-1.0 mg can potentially worsen sleep apnea in susceptible individuals 4

Special Populations

• For elderly patients, lower starting doses are recommended with careful monitoring 1
• Clonazepam is listed on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications in older adults 4
• Use with caution in patients with neurodegenerative disorders, obstructive sleep apnea, and underlying liver disease 4

Treatment Duration and Discontinuation

• There is no definitive evidence regarding how long patients should remain on clonazepam 1
• The physician should periodically reevaluate the long-term usefulness of the drug for the individual patient 1
• When discontinuing treatment, gradual tapering is essential to minimize withdrawal symptoms 5, 6
• A recommended tapering schedule is:
  • Decrease by 0.5 mg per 2-week period until 1 mg/day is reached 5
  • Then decrease by 0.25 mg per week until completely discontinued 5
• Gradual tapering has been shown to be well-tolerated without major withdrawal symptoms 5, 6