What is the clonazepam (Klonopin) equivalent dose for a patient taking Xanax (alprazolam) 2mg three times a day (TID)?

Benzodiazepine Dose Conversion: Alprazolam to Clonazepam

For a patient taking alprazolam (Xanax) 2mg TID (total daily dose 6mg), the clonazepam equivalent is approximately 3mg daily, typically divided as 1mg TID or 1.5mg BID.

Conversion Rationale

The standard benzodiazepine equivalency ratio between alprazolam and clonazepam is approximately 2:1, meaning 2mg of alprazolam equals roughly 1mg of clonazepam 1. This conversion is based on comparative potency studies in anxiety and panic disorders.

Calculation for This Patient:

• Current dose: Alprazolam 2mg TID = 6mg total daily dose
• Clonazepam equivalent: 6mg alprazolam ÷ 2 = 3mg clonazepam daily
• Suggested dosing schedule: 1mg TID or 1.5mg BID

Important Clinical Considerations

Pharmacokinetic Differences

Clonazepam has a significantly longer half-life (30-40 hours) compared to alprazolam (6-12 hours), which fundamentally changes the dosing dynamics 2. This longer half-life means:

• Less frequent dosing is required (BID may be sufficient instead of TID) 2
• More continuous anxiety control with less interdose breakthrough 1
• Slower onset of withdrawal symptoms if a dose is missed 2
• Greater accumulation with repeated dosing 2

Conversion Strategy

Start conservatively at 2.5-3mg daily divided BID or TID, as clonazepam's longer half-life provides more sustained coverage 3. The patient may actually require less than the calculated equivalent due to:

• Reduced peak-trough fluctuations 1
• Better 24-hour coverage with fewer doses 2
• Individual variation in CYP3A4 metabolism (clonazepam's primary metabolic pathway) 4

Critical Safety Warnings

Clonazepam carries significant risks that may be more pronounced than with alprazolam, particularly:

• Morning sedation and cognitive impairment - reported in up to 58% of patients in some studies 2, 3
• Falls and confusion risk - especially at doses ≥2mg, with potential for subdural hematoma 2, 3
• Worsening sleep apnea - even at doses of 0.5-1.0mg 2, 3
• Memory dysfunction and motor incoordination 2

Discontinuation Considerations

Alprazolam is notoriously difficult to discontinue with severe rebound and withdrawal symptoms, while clonazepam's longer half-life theoretically makes tapering easier 1. However:

• Patients on clonazepam typically cannot substantially reduce doses despite tapering attempts 2
• Same-night relapse can occur if clonazepam is missed 2
• Physical dependence develops with both agents 3

Monitoring Requirements

Before initiating clonazepam conversion:

• Screen for sleep apnea, gait disorders, and liver disease 3
• Perform baseline cognitive and motor coordination assessment 3
• Consider CYP3A4 expression testing if available, as low expressers require substantially lower doses (0.029 vs 0.058 mg/kg) 4

During ongoing treatment:

• Monitor for excessive sedation, particularly in the morning 2, 3
• Assess cognitive function and fall risk regularly 3
• Watch for signs of respiratory depression if sleep apnea is present 2

Practical Conversion Protocol

1. Day 1-3: Start clonazepam 0.5mg TID (1.5mg total) while continuing full alprazolam dose
2. Day 4-7: Increase clonazepam to 1mg TID (3mg total), reduce alprazolam by 50%
3. Day 8-10: Discontinue alprazolam completely, maintain clonazepam 3mg daily
4. Week 2-4: Adjust clonazepam dose based on response and tolerability, potentially reducing to BID dosing 3

The total daily clonazepam dose of 3mg represents the upper end of typical therapeutic dosing and requires careful monitoring for adverse effects 2, 3.