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

Klonopin Starting Dose for Adults

The starting dose of clonazepam (Klonopin) for adults is 0.25 mg twice daily for panic disorder, or up to 1.5 mg/day divided into three doses for seizure disorders. 1

Indication-Specific Dosing

For Panic Disorder

• Start with 0.25 mg twice daily 1
• The target therapeutic dose is 1 mg/day, which can be reached after 3 days 1
• This 1 mg/day dose has been shown to be optimal in fixed-dose studies, with higher doses (2-4 mg/day) being less effective and causing more adverse effects 1
• If needed, doses may be increased in increments of 0.125-0.25 mg twice daily every 3 days, up to a maximum of 4 mg/day 1
• To minimize somnolence, consider administering the full dose at bedtime 1

For Seizure Disorders

• Initial dose should not exceed 1.5 mg/day divided into three doses 1
• Increase by 0.5-1 mg every 3 days until seizures are controlled or side effects occur 1
• Maximum recommended daily dose is 20 mg 1

For REM Sleep Behavior Disorder

• Start with 0.25-0.5 mg at bedtime 2
• Most patients respond to low doses of 0.25-1.0 mg administered at bedtime 2
• The usual recommended dose range is 0.5-2.0 mg taken 30 minutes before bedtime 2
• Women may require higher dosing (mean 1.4 mg) compared to men (mean 0.68 mg) 2

For Persistent Pain in Older Adults (as muscle relaxant)

• Start with 0.25-0.5 mg at bedtime 2
• Monitor for sedation, memory impairment, and complete blood count 2

Special Population Considerations

Geriatric Patients

• Use lower starting doses in elderly patients across all indications 1
• Clonazepam appears on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications in older adults 2
• Start with 0.25 mg and titrate gradually, as older patients rarely tolerate doses greater than 30-40 mg per day for pain management 2

Pediatric Patients (Seizures)

• For infants and children up to 10 years or 30 kg: start with 0.01-0.03 mg/kg/day (not exceeding 0.05 mg/kg/day) given in 2-3 divided doses 1
• Increase by no more than 0.25-0.5 mg every third day until maintenance dose of 0.1-0.2 mg/kg is reached 1

Critical Safety Considerations

Common Side Effects to Monitor

• Somnolence is the most common adverse effect, particularly in the morning 2
• Other effects include sedation, memory dysfunction, early morning motor incoordination, and confusion 2
• Risk of falls and confusion, especially at doses of 2.0 mg nightly 2
• May worsen or cause sleep apnea at doses of 0.5-1.0 mg 2

Important Warnings

• Avoid abrupt discontinuation due to risk of withdrawal symptoms and seizures 2
• Use with caution in patients with obstructive sleep apnea, neurodegenerative disorders, and underlying liver disease 2
• Do not use in patients with Parkinson's disease or dementia with Lewy bodies when used for delirium, due to risk of extrapyramidal side effects 2
• Contraindicated in severe pulmonary insufficiency, severe liver disease, and myasthenia gravis 2

Drug Interactions

• Combining with benzodiazepines and high-dose olanzapine has resulted in fatalities 2
• May cause oversedation and respiratory depression when combined with other CNS depressants 2

Practical Prescribing Algorithm

1. Determine indication: Panic disorder requires lowest starting dose (0.25 mg BID); seizures allow up to 1.5 mg/day divided 1
2. Assess patient age: Elderly patients should start at the lower end of dosing ranges 1
3. Evaluate comorbidities: Reduce dose or avoid in sleep apnea, liver disease, or neurodegenerative conditions 2
4. Titrate slowly: Wait at least 3 days between dose increases to assess response and tolerability 1
5. Monitor closely: Watch for sedation, falls, cognitive impairment, and respiratory depression 2