Maximum Daily Dose of Clonazepam in Adults
The maximum recommended daily dose of clonazepam is 20 mg/day for seizure disorders and 4 mg/day for panic disorder, according to FDA labeling. 1
Dosing by Indication
Seizure Disorders
- Starting dose: 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 occur 1
- Maximum dose: 20 mg/day 1
- Maintenance: Individualized based on response, with the largest dose given before bedtime if doses are unequal 1
Panic Disorder
- Starting dose: 0.25 mg twice daily 1
- Target dose: 1 mg/day after 3 days, which is optimal for most patients 1
- Titration for higher doses: If needed, increase by 0.125-0.25 mg twice daily every 3 days 1
- Maximum dose: 4 mg/day 1
- Important caveat: Doses of 2-4 mg/day were actually less effective than 1 mg/day in fixed-dose studies and caused more adverse effects, so exceeding 1 mg/day should only occur if individual patients clearly benefit 1
REM Sleep Behavior Disorder
- Recommended range: 0.5-2.0 mg taken 30 minutes before bedtime 2
- Studied range: 0.25-4.0 mg 2
- Note: This is an off-label use, and the American Academy of Sleep Medicine suggests melatonin may be preferable due to fewer side effects 3
Critical Safety Considerations
Geriatric Patients
- Start with low doses and observe closely 1
- The American Geriatrics Society lists clonazepam as potentially inappropriate in older adults due to risks of somnolence, ataxia, depression, dizziness, fatigue, cognitive impairment, and falls 4
- Higher doses (2.0 mg) significantly increase fall risk 3
Pre-Treatment Screening Required
- Screen for sleep apnea (clonazepam can worsen or cause sleep apnea at doses as low as 0.5-1.0 mg) 4
- Assess for gait disorders, liver disease, and history of substance abuse 4
- Perform baseline neurological examination with attention to cognition 4
Common Pitfalls
- Tolerance development: Many studies report tolerance to anticonvulsant effects with chronic administration 5
- Withdrawal risk: Patients typically experience same-night relapse upon discontinuation, even after tapering attempts 4
- Long half-life: Elimination half-life is 30-40 hours, leading to accumulation and daytime sedation 3
- Therapeutic range: Blood concentrations of 15-50 mcg/L are considered therapeutic for seizure control 6, though there is large inter-individual variability 6
Discontinuation Protocol
- Reduce gradually by 0.125-0.25 mg twice daily every 3 days for panic disorder 1
- For patients on chronic therapy (>3 years), decrease by 0.5 mg per 2-week period until 1 mg/day is reached, then by 0.25 mg per week 7
- Withdrawal symptoms are usually mild but include anxiety, tremor, nausea, insomnia, sweating, tachycardia, and headache 7