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

Starting Dose of Clonazepam for Anxiety

The recommended starting dose of clonazepam for anxiety is 0.25-0.5 mg orally, taken up to three times daily, with careful titration based on response and tolerability. 1, 2

Initial Dosing Guidelines

• For most adults with anxiety disorders, begin with 0.25 mg twice daily or 0.5 mg at bedtime 1, 2
• Lower starting doses (0.25 mg once daily) are recommended for elderly patients, those with hepatic impairment, or debilitated individuals 3, 1
• Maximum daily dose should generally not exceed 4 mg, though most patients respond to 1-2 mg daily 2, 4
• Clonazepam reaches maximum plasma concentrations within 1-4 hours after oral administration, with a long elimination half-life of 30-40 hours 2

Dosage Adjustment and Monitoring

• After initial dosing, titrate gradually by 0.25-0.5 mg increments every 3-7 days based on clinical response 1, 4
• Monitor for common side effects including sedation, ataxia, impaired coordination, memory dysfunction, and confusion 3, 2
• For panic disorder specifically, daily dosages of 1.0-2.0 mg offer the best balance of therapeutic benefit and tolerability 4
• Patients should be evaluated for response within 2-4 weeks of reaching a stable dose 5

Special Considerations

• Use with caution in patients with:
  • Neurodegenerative disorders due to increased risk of confusion 3
  • Obstructive sleep apnea as clonazepam may worsen respiratory depression 3
  • Underlying liver disease, as hepatic metabolism affects clearance 2
• Avoid abrupt discontinuation after prolonged use; taper gradually to prevent withdrawal symptoms 6
• When discontinuing after long-term use, consider reducing by 0.25 mg weekly after reaching 1 mg daily 6

Pharmacological Properties

• Clonazepam is a long-acting benzodiazepine with high bioavailability (approximately 90%) 2
• It is highly protein-bound (85%) and extensively metabolized by the liver, primarily through CYP3A pathways 2
• Less than 2% is excreted unchanged in urine, making it relatively safe in patients with renal impairment 2

Clinical Pearls

• Lorazepam (0.5-1 mg) may be an alternative for patients with hepatic impairment due to its simpler metabolism 3
• For anxiety with comorbid depression, consider adding an SSRI after stabilization on clonazepam 5
• Tolerance development is variable, but many patients maintain efficacy at stable doses without significant dose escalation 7, 8
• Morning drowsiness is one of the most common side effects requiring dose adjustment or timing modification 3