Clonazepam

Generic name Clonazepam

Available brand Klonopin
Available strengths and formulations 0.5-mg, 1-mg, and 2-mg tablets
0.125-mg, 0.25-mg, 0.5-mg, 1-mg, and 2-mg orally
disintegrating tablets (dissolve rapidly)
Available in generic Yes

GENERAL INFORMATION
Clonazepam, commonly known by its trade name Klonopin, is classified with similar medications
called benzodiazepines. Clonazepam is used primarily in the management of seizure disorders and
panic disorder. The use of a medication for its U.S. Food and Drug Administration–approved indications
is called its labeled use. In clinical practice, however, practitioners frequently use medications for unap-
proved indications (off-label uses) when published clinical studies indicate the efficacy, and the standards of
medical practice support the safety, of those treatments. Clonazepam’s off-label uses, for example,
include treatment of social anxiety disorder, posttraumatic stress disorder, agitation in acute psychosis
and mania, and premenstrual syndrome. As with other benzodiazepines, clonazepam is associated with
dependence and abuse and is therefore regulated as a controlled substance by federal and state laws.

DOSING INFORMATION
The usual starting dosage of clonazepam is 0.5 mg two to three times a day, with increases to a therapeu-
tic dosage of 1–4 mg/day administered in divided doses. Depending on the severity of symptoms, the
dosage may be increased to a recommended maximum of 6–8 mg/day.

COMMON SIDE EFFECTS

The most common side effects associated with clonazepam are sedation and drowsiness, especially
shortly after initiation of therapy. Other frequent symptoms are impaired concentration and memory,
feeling of dissociation (feeling “spacey”), and impaired coordination.

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ADVERSE REACTIONS AND PRECAUTIONS

Clonazepam affects alertness and coordination, and patients should exercise caution when driving or
performing other tasks requiring alertness while taking this medication. Elderly patients may be more
adversely affected because it may affect their coordination and reflexes and lead to falls and injury. Tak-
ing clonazepam with other central nervous system (CNS) depressants such as alcohol, narcotics, antihis-
tamines, and barbiturates may compound these CNS effects.
Prolonged use of benzodiazepines can lead to dependence. When the medication is abruptly stopped,
symptoms of withdrawal may occur. Withdrawal symptoms include headache, vomiting, impaired con-
centration, confusion, tremor, muscle cramps, and seizures. However, because clonazepam has a long
duration of action, withdrawal symptoms are generally milder than with shorter-acting benzodiaze-
pines, such as alprazolam (Xanax).
Benzodiazepines are centrally acting depressants, and they can cause respiratory distress, decreasing
ability to breathe. This is particularly problematic for patients with chronic obstructive pulmonary dis-
ease and emphysema. Patients with sleep apnea—a sleep disorder in which respiration is interrupted by
long pauses during the sleep cycle—should not take clonazepam or other benzodiazepines.
Benzodiazepines may cause excitement, aggression, anger, uninhibited behavior, and rage in suscep-
tible individuals. These reactions are more likely to occur in elderly patients, people with brain damage,
and individuals with personality and impulse-control disorders.

RISK DURING PREGNANCY AND BREAST-FEEDING

Benzodiazepines, including clonazepam, and their metabolites are known to cross the placenta and accu-
mulate in the fetal circulation. They have been associated with birth defects when used during pregnancy.
Clonazepam should be avoided during pregnancy, especially in the first trimester. Benzodiazepines may
induce withdrawal symptoms and respiratory problems in the baby after delivery. They should not be
used during pregnancy unless the potential benefits outweigh the potential risk to the fetus and safer
alternative therapies have failed. Women of childbearing age should be cautioned of the potential hazards
to the fetus if they become pregnant while taking this drug. If a woman becomes pregnant while taking
clonazepam, she should consult her medical practitioner right away.
Nursing mothers should not take clonazepam because it can pass into breast milk and be ingested by
the baby. If stopping the drug is not an alternative, breast-feeding should not be started or should be dis-
continued.

POTENTIAL DRUG INTERACTIONS

Patients taking clonazepam should not consume alcohol or take other sedating medications, such as bar-
biturates, narcotics, sleep medications, and antihistamines, because combining alcohol or these medica-
tions with clonazepam can increase sedation and drowsiness, impair coordination and alertness, and
depress respiration. Benzodiazepines in combination with narcotics or alcohol are especially dangerous
in cases of overdose.
Some medications can interfere with the breakdown (metabolism) of clonazepam in the liver, which
may therefore increase the levels of the drug in the body, leading to increased sedation, drowsiness and
other CNS side effects. Oral antifungal agents known as azoles (e.g., itraconazole, ketoconazole, flucon-
azole), anti-HIV drugs known as protease inhibitors (e.g., indinavir, nelfinavir, ritonavir), and certain an-
tibiotics (e.g., clarithromycin, erythromycin) can interfere with the metabolism of clonazepam.

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OVERDOSE
Most fatalities reported with benzodiazepines involve multiple medication ingestion, particularly the
combination of a benzodiazepine with other CNS depressants, such as alcohol, narcotics, antihistamines,
and barbiturates.
Mild symptoms of benzodiazepine overdose include drowsiness, confusion, somnolence, tiredness,
ataxia (impaired coordination in voluntary movements), and slow reflexes. Benzodiazepine overdose,
when these agents are taken alone, is rarely fatal. When multiple medications are implicated in benzodi-
azepine overdose, severe symptoms include difficulty breathing, slowed heart rate, low blood pressure,
loss of coordination, loss of consciousness leading to coma, and, potentially, death. Acute overdose of a
benzodiazepine in combination with opioids, tricyclic antidepressants, alcohol, or barbiturates is partic-
ularly dangerous and often fatal.
Any suspected overdose should be treated as an emergency. The person should be taken to the emer-
gency department for observation and treatment. The prescription bottle of medication (and any other
medication suspected in the overdose) should be brought along as well because the information on the
prescription label can be helpful to the treating practitioner in determining the number of pills ingested.
The American Association of Poison Control Centers (www.aapcc.org) can also be contacted via their
helpline at 1-800-222-1222, and they can provide the location of the local poison center.

TREATMENT SUMMARY

• Do not discontinue clonazepam without consulting your practitioner. Clonazepam should be discon-
tinued gradually by tapering the dose. Stopping the medication abruptly, especially after taking it
regularly for long periods, may trigger withdrawal symptoms, including irritability, agitation, ten-
sion, and insomnia.
• If you miss a dose, take it as soon as possible. If it is close to the next scheduled dose, skip the missed
dose and continue on your regular dosing schedule. Do not take double doses.
• Clonazepam may be taken with or without food.
• Clonazepam may cause sedation and drowsiness, especially during initiation of therapy, and impair
your alertness. Use caution when driving or performing tasks that require alertness. Avoid alcohol
while taking clonazepam because alcohol may intensify these effects.
• Store the medication in its originally labeled, light-resistant container, away from heat and moisture.
Heat and moisture may precipitate breakdown of your medication, and the medication may lose its
therapeutic effects.
• Keep your medication out of the reach of children.

If you have any questions about your medication, consult your medical practitioner or pharmacist.

Copyright © 2017 American Psychiatric Association. The purchaser of this book is licensed to distribute copies of these handouts
in limited amounts. Please see copyright page for further information. The authors have worked to ensure that all information on
this handout concerning drug dosages, schedules, routes of administration, and side effects is accurate as of the time of publication
and consistent with standards set by the U.S. Food and Drug Administration and the general medical community and accepted
psychiatric practice. This handout does not cover all possible uses, precautions, side effects, or interactions of the drug. For a com-
plete listing of side effects, see the manufacturer’s package insert, which can be obtained from your physician or pharmacist. As
medical research and practice advance, therapeutic standards may change. For this reason, and because human and mechanical
errors sometimes occur, we recommend that readers follow the advice of a physician who is directly involved in their care or the
care of a member of their family.
From Chew RH, Hales RE, Yudofsky SC: What Your Patients Need to Know About Psychiatric Medications, Third Edition. Arling-
ton, VA, American Psychiatric Association Publishing, 2017

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