Clonazepam Dosage and Usage
For seizure disorders, start adults at 1.5 mg/day divided into three doses and titrate by 0.5-1 mg every 3 days up to a maximum of 20 mg/day; for panic disorder, start at 0.25 mg twice daily and increase to a target of 1 mg/day after 3 days, with a maximum of 4 mg/day if needed. 1
Seizure Disorders
Adult Dosing
- Initial dose: Do not exceed 1.5 mg/day divided into three doses 1
- Titration: Increase by 0.5-1 mg every 3 days until seizures are controlled or side effects emerge 1
- Maximum dose: 20 mg/day 1
- Mechanism: Clonazepam has been used for seizure disorders since 1976, with a therapeutic serum concentration of 5-50 ng/ml and biological half-life of 22-32 hours 2
Pediatric Dosing (up to 10 years or 30 kg)
- Initial dose: 0.01-0.03 mg/kg/day (not exceeding 0.05 mg/kg/day) given in 2-3 divided doses 1
- Titration: Increase by no more than 0.25-0.5 mg every third day 1
- Target maintenance: 0.1-0.2 mg/kg/day, divided into three equal doses (largest dose before bedtime if unequal) 1
Geriatric Considerations
- Start on low doses and observe closely due to increased sensitivity to sedating effects and prolonged metabolism 1
- Clonazepam is listed on the American Geriatrics Society Beers Criteria as potentially inappropriate in older adults 3, 4
Panic Disorder
Adult Dosing
- Initial dose: 0.25 mg twice daily 1
- Target dose: 1 mg/day after 3 days, which represents the optimal dose based on fixed-dose studies 1, 5
- Titration for higher doses: If needed, increase by 0.125-0.25 mg twice daily every 3 days 1
- Maximum dose: 4 mg/day, though doses of 1-2 mg/day offer the best balance of benefit and tolerability 1, 5
- Administration tip: Single bedtime dosing may reduce daytime somnolence 1
- Historical efficacy: At a mean dose of 1.9 mg/day, 78% of patients with panic disorder or agoraphobia responded to treatment 6
Discontinuation
- Taper gradually by decreasing 0.125 mg twice daily every 3 days until completely withdrawn 1
- Most patients tolerate discontinuation with this tapering schedule, though some worsening may occur without reverting to baseline 5
Critical Warnings and Side Effects
Common Adverse Effects
- Dose-related: Drowsiness, ataxia, and behavioral changes occur early but may subside with chronic use 2
- Panic disorder-specific: Somnolence and ataxia more common at 3-4 mg/day; depression, dizziness, fatigue, and irritability reported more frequently than placebo 5
- RBD context: Morning sedation, gait imbalance/falls, depression, cognitive disturbances (delirium, amnesia) 3
Serious Concerns
- Sleep-disordered breathing: Doses of 0.5-1.0 mg can worsen sleep apnea 4
- Cognitive impairment: Progressive decline combined with age-related impaired metabolism often leads to intolerance, particularly in neurodegenerative disease 3
- Falls risk: Especially at higher doses (2.0 mg), particularly concerning in elderly patients 4
- Tolerance: Many studies report tolerance to anticonvulsant effects with chronic administration 2
Special Populations Requiring Caution
- Older adults (>50 years): More sensitive to sedating effects, longer metabolism time, increased fall risk 3
- Neurodegenerative disease: Often requires lower starting doses (0.25 mg) due to cognitive decline and drug metabolism impairment 3
- Pediatric panic disorder: No clinical trial experience in patients under 18 years 1
- Geriatric panic disorder: No clinical trial experience in patients 65 years and older; start low and observe closely 1
Clinical Pearls
When to Consider Alternatives
- REM sleep behavior disorder: Melatonin (3-15 mg) may be preferable due to fewer side effects, particularly in older adults or those with neurodegenerative disease 3, 4
- Stigma concerns: Some patients hesitate to start clonazepam due to negative perceptions of benzodiazepines 3
- Controlled substance status: Clonazepam is prescription-only and regulated as a controlled substance 3