Does clonazepam (Klonopin) decrease or increase tremor?

Clonazepam Decreases Tremor

Clonazepam is effective in reducing tremor, particularly for specific tremor subtypes including essential tremor variants, kinetic predominant tremor, and orthostatic tremor. 1, 2, 3

Evidence for Tremor Reduction

Essential Tremor and Variants

• Clonazepam possibly reduces limb tremor in essential tremor (Level C evidence), though it is not a first-line agent 4
• Clonazepam was the only drug effective in some cases of kinetic predominant tremor and orthostatic truncal tremor where propranolol and primidone failed 2
• For primary orthostatic tremor specifically, clonazepam is the first-line treatment, with surface electromyography showing characteristic 14-18 Hz tremor 3

Clinical Context

• Benzodiazepines like clonazepam can provide benefit when first-line agents (primidone or propranolol) do not provide adequate tremor control 1
• If tremor is disabling only during periods of stress and anxiety, benzodiazepines can be used during those specific periods when tremor causes functional disability 1

Important Caveats and Pitfalls

Withdrawal Effects

• Abrupt discontinuation causes tremor as a withdrawal symptom in neonates exposed in utero, with tremors appearing within hours to weeks and potentially lasting 1.5-9 months 5
• In adults, failure to take clonazepam can result in immediate relapse of symptoms, with rapid control restored after resumption 6

Side Effects to Monitor

• Sedation is a major side effect but decreases in most patients with time 7
• Memory impairment may occur during use, which can improve after stopping 8
• Enhanced sedation, increased fall risk, cognitive impairment, and impaired coordination can occur, especially when combined with other CNS depressants 9

Treatment Algorithm

1. First-line for orthostatic tremor: Start clonazepam 3
2. For essential tremor: Use only after propranolol and primidone have failed or in combination with these agents 1, 4
3. For stress-induced tremor: Use intermittently during periods of functional disability 1
4. If clonazepam fails: Consider primidone or gabapentin as alternatives for orthostatic tremor 3

Dosing Considerations

• Clonazepam has a long half-life (30-40 hours), which prolongs both therapeutic and adverse effects 9
• Start with lower doses, particularly in elderly patients or those with hepatic impairment 9