What is clonazepam used for and how is it prescribed?

Clonazepam: Indications and Prescribing

Clonazepam is FDA-approved for treating certain seizure disorders (Lennox-Gastaut syndrome, akinetic, and myoclonic seizures) and panic disorder with or without agoraphobia in adults, and should be prescribed starting at low doses with gradual titration while monitoring for sedation, falls, and dependence. 1

FDA-Approved Indications

Seizure Disorders

• Clonazepam is indicated for Lennox-Gastaut syndrome (petit mal variant), akinetic seizures, and myoclonic seizures, either alone or as adjunctive therapy. 1
• It may be useful in absence seizures (petit mal) when succinimides have failed. 1
• Clinicians should be aware that some loss of effect may occur during treatment due to tolerance development. 1

Panic Disorder

• Clonazepam is approved for panic disorder with or without agoraphobia in adults, characterized by recurrent unexpected panic attacks with at least four associated symptoms (palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, fear of losing control, etc.). 1
• Efficacy was established in 6-9 week trials, but long-term effectiveness beyond 9 weeks has not been systematically studied in controlled trials. 1
• Physicians using clonazepam for extended periods should periodically reevaluate its usefulness for each patient. 1

How Clonazepam is Prescribed

Starting Doses and Titration

• For panic disorder, clonazepam should be started at low doses and titrated gradually based on response and tolerability. 2
• When used as adjunctive therapy for depression (off-label), recommended dosing is 2.5-6.0 mg/day in combination with SSRIs, with response expected within 2-4 weeks. 3
• In older adults, particularly low starting doses are essential—the American Geriatrics Society Beers Criteria lists clonazepam as potentially inappropriate in older adults due to risks of sedation, falls, and cognitive impairment. 4

Administration

• Clonazepam tablets should be taken with water and swallowed whole. 1
• The long elimination half-life of 30-40 hours allows for less frequent dosing but increases risk of daytime sedation. 4

Duration of Treatment

• For seizure control, treatment is typically long-term, but physicians must monitor for tolerance development. 1
• For panic disorder, while acute efficacy is established, the decision to continue beyond 9 weeks should be individualized with periodic reassessment. 1

Critical Safety Warnings

Black Box Equivalent Warnings

• Clonazepam is a Schedule IV controlled substance with potential for abuse and dependence—never stop abruptly as this can cause life-threatening status epilepticus (seizures that won't stop). 1
• When combined with opioids, clonazepam can cause severe respiratory depression, coma, and death. 1
• Like other antiepileptic drugs, clonazepam carries risk of suicidal thoughts or actions in approximately 1 in 500 patients—monitor for new or worsening depression, anxiety, agitation, or suicidal ideation. 1

Common Side Effects Impacting Function

• Clonazepam causes drowsiness, dizziness, and impaired coordination—patients must not drive or operate machinery until they know how it affects them. 1
• Do not combine with alcohol or other CNS depressants as this significantly worsens sedation and dizziness. 1
• Morning sedation, confusion, memory dysfunction, and increased fall risk are particularly problematic in older adults. 4
• Clonazepam at doses of 0.5-1.0 mg can worsen sleep apnea. 4

Special Populations

• Pregnancy: Studies in animals show harmful effects on the fetus; infants born to mothers taking clonazepam late in pregnancy may experience breathing problems, feeding difficulties, hypothermia, and withdrawal symptoms. 1
• Breastfeeding: Clonazepam passes into breast milk—discuss feeding options with healthcare provider. 1
• Contraindications: Do not use in patients with significant liver disease, acute narrow-angle glaucoma, or benzodiazepine allergy. 1

Discontinuation Protocol

When discontinuing clonazepam after long-term use (≥3 years), taper by 0.5 mg every 2 weeks until reaching 1 mg/day, then decrease by 0.25 mg per week to minimize withdrawal symptoms. 5

• Abrupt discontinuation can cause seizures, hallucinations, tremors, and severe muscle cramps. 1
• Withdrawal symptoms are typically mild when tapered properly and include anxiety, tremor, nausea, insomnia, sweating, tachycardia, and headache. 5
• Most patients (68.9%) can successfully discontinue within 4 months using this protocol, with another 26% requiring an additional 3 months. 5
• Physical dependence develops with regular use but is distinct from addiction—failure to take clonazepam after developing dependence results in immediate symptom relapse. 6

Off-Label Uses (Not FDA-Approved)

While clonazepam has been studied for various psychiatric conditions, these uses lack FDA approval:

• Adjunctive treatment for depression (more effective in unipolar than bipolar depression). 3
• REM sleep behavior disorder (though it doesn't normalize sleep architecture and may worsen sleep apnea—melatonin 3-12 mg is preferred by the American Academy of Sleep Medicine due to better safety profile). 4
• Neuropathic pain refractory to other treatments (minimal evidence, rarely considered due to adverse effect risks in older adults). 7