What is the starting dose of clonazepam (Klonopin) for adults?

Starting Dose of Clonazepam for Adults

The recommended starting dose of clonazepam for adults is 0.25 mg to 0.5 mg administered orally at bedtime, with gradual titration based on response and tolerability. 1, 2

Dosing Guidelines by Indication

Panic Disorder

• Initial dose: 0.25 mg twice daily 1
• Target dose: 1 mg/day (can be increased after 3 days) 1
• Maximum dose: 4 mg/day (though 1 mg/day is often optimal) 1, 3
• Administration: May be given as a single bedtime dose to reduce daytime somnolence 1

REM Sleep Behavior Disorder (RBD)

• Initial dose: 0.25-0.5 mg at bedtime 2
• Effective dose range: 0.25-1.0 mg at bedtime 2
• Maximum dose: Up to 2.0 mg may be considered if lower doses are ineffective and well tolerated 2

Seizure Disorders

• Initial dose: Should not exceed 1.5 mg/day divided into three doses 1
• Titration: May increase by 0.5-1.0 mg every 3 days until seizures are controlled 1
• Maximum dose: 20 mg/day 1

Special Populations

Elderly Patients

• Start with lower doses (0.25 mg) 1, 2
• Observe closely for side effects 1
• Use with caution as clonazepam is on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications in older adults 2

Patients with Hepatic Impairment

• Lower starting doses are recommended 2
• Monitor for signs of hepatic dysfunction 2

Titration and Maintenance

• Increase dose gradually based on clinical response 1, 3
• For panic disorder: Increase by 0.125-0.25 mg twice daily every 3 days as needed 1
• For RBD: Most patients respond to low doses (0.25-1.0 mg) without need for significant dose escalation 2
• Minimal dosage tolerance has been reported with long-term use for RBD 2

Common Side Effects to Monitor

• Sedation (most common side effect, particularly morning sedation) 2
• Ataxia and impaired coordination 2, 3
• Memory dysfunction 2
• Potential worsening of sleep apnea 2
• Confusion (particularly in elderly) 2

Important Clinical Considerations

• Clonazepam is a long-acting benzodiazepine with an elimination half-life of 30-40 hours 2
• Maximum plasma concentrations are reached within 1-4 hours after oral administration 2
• For RBD, clonazepam reduces dream enactment with minimal reduction in REM sleep motor tone 2
• When discontinuing, taper gradually to avoid withdrawal symptoms (e.g., 0.25 mg/week) 1, 4
• Combination therapy with melatonin may be considered for RBD if monotherapy response is inadequate 2

Cautions and Contraindications

• Use with caution in patients with neurodegenerative disorders 2
• Use with caution in patients with obstructive sleep apnea 2
• Use with caution in patients with underlying liver disease 2
• Avoid in patients with severe pulmonary insufficiency 2
• Avoid in patients with myasthenia gravis 2