What is Rivotril (clonazepam) used for?

What is Rivotril (Clonazepam) Used For?

Rivotril (clonazepam) is FDA-approved for treating certain seizure disorders (including Lennox-Gastaut syndrome, akinetic, myoclonic, and absence seizures) and panic disorder with or without agoraphobia in adults. 1

FDA-Approved Indications

Seizure Disorders

• Clonazepam is indicated for Lennox-Gastaut syndrome (petit mal variant), akinetic seizures, and myoclonic seizures, either as monotherapy or adjunctive treatment 1
• For absence seizures (petit mal) that have failed succinimide therapy, clonazepam may be useful 1
• Note that tolerance (loss of effect) may develop during chronic treatment, requiring dose adjustments 1, 2

Panic Disorder

• Clonazepam is FDA-approved for panic disorder with or without agoraphobia as defined in DSM-V criteria 1
• Panic disorder is characterized by recurrent unexpected panic attacks with at least four symptoms including palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, or fear of losing control 1
• Efficacy was established in 6-9 week trials, though long-term effectiveness beyond 9 weeks has not been systematically studied in controlled trials 1
• Clonazepam remains effective alone or combined with SSRIs and/or behavioral therapy for panic disorder management 3

Off-Label Uses Supported by Guidelines

REM Sleep Behavior Disorder (RBD)

• The American Academy of Sleep Medicine conditionally recommends clonazepam for secondary RBD due to medical conditions (particularly Parkinson's disease and dementia with Lewy bodies) in adults 4
• Typical dosing is 0.25-2.0 mg taken 1-2 hours before bedtime, with most patients responding to 0.5-1.0 mg 5
• Clonazepam reduces sleep-related injuries in RBD from 80.8% pre-treatment to 5.6% post-treatment 5

However, critical caveats apply: Clonazepam does not restore normal REM sleep architecture or REM atonia—it primarily suppresses locomotor activity at the brainstem level without normalizing sleep physiology 6, 5. Melatonin (3-12 mg at bedtime) should be strongly considered as first-line therapy instead, particularly for elderly patients, those with dementia, patients at fall risk, or those with sleep apnea 6, 7, 5

Treatment-Resistant Depression (Adjunctive)

• Clonazepam has been used as adjunctive therapy to accelerate response to conventional antidepressants, particularly SSRIs 8
• When used for depression, dosing is typically 2.5-6.0 mg/day, with response expected within 2-4 weeks 8
• It is significantly more effective for unipolar than bipolar depression 8

Critical Safety Warnings

High-Risk Populations Requiring Extreme Caution

• Elderly patients are at increased risk for falls, confusion, subdural hematoma (especially at doses ≥2.0 mg), and prolonged sedation due to slower metabolism (half-life 30-40 hours) 6, 5, 1
• The American Geriatrics Society Beers Criteria lists clonazepam as potentially inappropriate in older adults 6, 7
• Patients with dementia experience moderate-to-severe side effects, with 36% requiring discontinuation 5
• Clonazepam at doses of 0.5-1.0 mg can worsen obstructive sleep apnea 6, 5, 1

Serious Adverse Effects

• Common side effects include daytime sleepiness, dizziness, postural instability, cognitive impairment, and morning sedation 4, 1
• Antiepileptic drugs including clonazepam may cause suicidal thoughts or actions in approximately 1 in 500 people 1
• Clonazepam can cause severe drowsiness, respiratory depression, coma, and death when combined with opioids 1
• Physical dependence and tolerance develop with prolonged use 1, 9, 2

Contraindications

• Do not use in patients with benzodiazepine allergy, significant liver disease, or acute narrow-angle glaucoma 1
• Abrupt discontinuation can cause status epilepticus (seizures that will not stop) and severe withdrawal symptoms including hallucinations, shaking, and muscle cramps 1

Dosing Considerations

Starting Doses

• For most indications, start with 0.25-0.5 mg at bedtime 5
• Dosage should be increased slowly over 2-4 weeks to minimize side effects like drowsiness, ataxia, and behavioral changes 2, 10

Monitoring Requirements

• Before initiating therapy, perform baseline neurological examination with attention to cognition and extrapyramidal signs 5
• Screen for sleep apnea, gait disorders, and liver disease 5
• During treatment, monitor for cognitive decline, motor coordination, and periodically reassess necessity of continued therapy 5

Key Clinical Pitfalls

• Patients typically cannot substantially reduce doses despite tapering attempts, with same-night relapse upon discontinuation 5
• Clonazepam is a federal controlled substance (C-IV) due to abuse and dependence potential 1, 9
• Pregnancy considerations: Studies in pregnant animals show harmful effects on the developing fetus; neonates may experience breathing problems, feeding difficulties, hypothermia, and withdrawal symptoms 1
• Breastfeeding: Clonazepam passes into breast milk 1