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

Maximum Dose of Clonazepam in Anxiety

The maximum recommended dose of clonazepam for panic disorder (the FDA-approved anxiety indication) is 4 mg per day, though the optimal therapeutic dose for most patients is 1 mg per day. 1

FDA-Approved Dosing for Panic Disorder

• The initial dose should be 0.25 mg twice daily (0.5 mg/day total), with an increase to the target dose of 1 mg/day after 3 days. 1
• The absolute maximum dose is 4 mg per day, though doses above 1 mg/day show diminishing returns in efficacy while increasing adverse effects. 1, 2
• Dose increases beyond 1 mg/day should be made in increments of 0.125-0.25 mg twice daily every 3 days, only if the patient has not achieved adequate control at lower doses. 1

Evidence-Based Optimal Dosing

The FDA labeling is supported by high-quality dose-response studies that clarify the risk-benefit profile:

• Daily doses of 1.0-2.0 mg offer the best balance of therapeutic benefit and tolerability for panic disorder. 2
• The minimum effective dose is 1.0 mg daily, with doses of 1.0 mg and higher showing equal efficacy in reducing panic attacks. 2
• Doses of 3.0-4.0 mg daily are associated with significantly more adverse effects (particularly somnolence and ataxia) without additional therapeutic benefit compared to 1.0-2.0 mg daily. 2
• In long-term treatment studies, most patients are effectively maintained at 2-3 mg/day, with a mean dose of 2.7 mg/day in patients treated for at least 3 years. 3, 4

Practical Dosing Algorithm

Start at 0.25 mg twice daily and titrate as follows: 1

• After 3 days: Increase to 0.5 mg twice daily (1 mg/day total) - this is the target dose for most patients 1, 2
• If inadequate response after 1-2 weeks at 1 mg/day: Increase to 1 mg twice daily (2 mg/day total) 1, 2
• If still inadequate response: Consider increasing to 3-4 mg/day in divided doses, but expect increased side effects without guaranteed additional benefit 1, 2
• To minimize somnolence, consider giving a single dose at bedtime rather than divided doses once the patient is stabilized 1

Critical Caveats

• Elderly patients should start at lower doses (0.125-0.25 mg twice daily) and be observed closely, as they are at higher risk for confusion, falls, and respiratory depression. 1
• Clonazepam should be used with extreme caution in patients with obstructive sleep apnea, as doses of 0.5-1.0 mg can worsen or precipitate sleep apnea. 5
• The risk of confusion, falls, and subdural hematoma increases at doses of 2.0 mg or higher, particularly in elderly or neurodegenerative disease patients. 5
• Morning sedation, motor incoordination, and cognitive impairment are common dose-related side effects that may necessitate dose reduction or discontinuation. 5

Duration and Discontinuation Considerations

• Clonazepam should be tapered gradually when discontinuing: reduce by 0.25 mg per week once daily dose reaches 1 mg/day, then by 0.5 mg every 2 weeks for higher doses. 3
• Abrupt discontinuation results in immediate symptom relapse, but gradual tapering is well-tolerated without significant withdrawal syndrome. 5, 6, 3
• Physicians should periodically reevaluate the need for continued treatment, as there is limited evidence for optimal duration of therapy. 1