II. Class

  1. Long acting Benzodiazepine

III. Indications

  1. Anxiety Disorder
  2. Tic Disorder or Tourette's Syndrome
  3. Seizure Disorder
    1. Lennox-Gastaut Syndrome
    2. Akinetic Seizure
    3. Myoclonic Seizure

IV. Contraindications

  1. Hepatic Failure
  2. Narrow Angle Glaucoma

V. Dosing: Adults

  1. Panic Disorder or Generalized Anxiety Disorder
    1. Start 0.25 orally twice daily
    2. Titrate: Increase by 0.125 to 0.25 every 3 days to typical target dose of 1 mg/day divided
    3. Maximum Daily Dose: 4 mg (1.5 mg/day in elderly)
      1. No evidence of benefit for total daily dose above 1 to 2 mg
  2. Akinetic or Myoclonic Seizures or Lennox-Gestaut Syndrome (type of Petit Mal Seizures)
    1. Start 0.5 mg orally three times daily
    2. May increase dose by 0.5 to 1 mg orally every 3 days as needed to typical 2 to 8 mg/day in divided doses
    3. Maximum: 20 mg/day
  3. REM Sleep Behavior Disorder (Not FDA approved)
    1. Dose 1 to 2 mg orally at bedtime

VI. Dosing: Children (age <10 years or weight <30 kg)

  1. Akinetic or Myoclonic Seizures or Lennox-Gestaut Syndrome (type of Petit Mal Seizures)
    1. Start 0.01 to 0.03 mg/kg/day orally divided 2 to 3 times daily
    2. May increase dose by 0.25 to 0.5 mg orally every 3 days as needed
    3. Maximum: 0.1 to 0.2 mg/day divided 2 to 3 times daily

VII. Dosing: Equivalent Dosing (for Benzodiazepine Withdrawal)

  1. Valium = Clonazepam Dose x2.5
  2. Phenobarbital = Clonazepam Dose x7.5

VIII. Pharmacokinetics

  1. Half Life: 20-48 hours (up to 60 hours)
  2. Therapeutic Range: 20 to 80 ng/ml
  3. Rapidly and completely absorbed PO
  4. Metabolized via CYP3A4 to inactive metabolites

IX. Safety

  1. Pregnancy Category D (esp. avoid in first trimester)
  2. Avoid in Lactation
  3. Schedule IV Controlled Substance

X. Adverse Effects

  1. Sedation
  2. Weight gain
  3. Impaired academic performance
  4. Social anxiety with School Refusal in children
  5. Worsening of attention in children with ADHD
  6. Hypersalivation

XII. References

  1. (2019) Med Lett Drugs Ther 61(1578): 121-6
  2. (2020) Presc Lett, Resource #361206, Appropriate Use of Benzodiazepines
  3. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 55
  4. Hamilton (2020) Tarascon Pocket Pharmacopoeia

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