clonazepam

ROUTE	ONSET	PEAK	DURATION
PO	20–60 min	1–2 hr	6–12 hr

Contraindicated in:

Hypersensitivity to clonazepam or other benzodiazepines;
Severe hepatic impairment.

Use Cautiously in:

All patients (may ↑ risk of suicidal thoughts/behaviors);
Angle-closure glaucoma;
Obstructive sleep apnea;
Chronic respiratory disease;
History of porphyria;
OB: Use late in pregnancy can result in sedation (respiratory depression, lethargy, hypotonia) and/or withdrawal symptoms (hyperreflexia, irritability, restlessness, tremors, inconsolable crying, and feeding difficulties) in neonates
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety and effectiveness not established in children for panic disorder;
Geri: Appears on Beers list. risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. If possible, avoid use in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: palpitations

Derm: rash

EENT: diplopia, nystagmus

GI: constipation, diarrhea, hepatitis

GU: dysuria, nocturia, urinary retention

Hemat: anemia, eosinophilia, leukopenia, thrombocytopenia

Metab: weight gain

Neuro: ataxia, behavioral changes, drowsiness, fatigue, hypotonia, sedation, slurred speech, SUICIDAL THOUGHTS

Resp: ↑secretions

Misc: fever, physical dependence, psychological dependence, tolerance

Interactions ⬆ ⬇

Drug-drug:

Use with opioids or other CNS depressants, including other benzodiazepines, non-benzodiazepine sedative/hypnotics, anxiolytics, general anesthetics, muscle relaxants, antipsychotics, and alcohol may cause profound sedation, respiratory depression, coma, and death; reserve concurrent use for when alternative treatment options are inadequate.
Cimetidine, hormonal contraceptives, disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, propranolol, or valproic acid may ↓ metabolism and ↑ toxicity of clonazepam.
May ↓ efficacy of levodopa.
Rifampin or barbiturates may ↑ metabolism and ↓ effectiveness.
Sedative effects may be ↓ by theophylline.
May ↑ phenytoin levels.
Phenytoin may ↓ levels.

Drug-Natural Products:

Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression.

Route/Dosage ⬆ ⬇

PO (Adults ): 0.5 mg 3 times daily; may ↑ by 0.5–1 mg every 3 days. Total daily maintenance dose not to exceed 20 mg. Panic disorder: 0.125 mg twice daily; ↑ after 3 days toward target dose of 1 mg/day (some patients may require up to 4 mg/day).
PO (Children ≤10 yr or ≤30 kg): Initial daily dose 0.01–0.03 mg/kg/day (not to exceed 0.05 mg/kg/day) given in 2–3 equally divided doses; ↑ by no more than 0.25–0.5 mg every 3 days until therapeutic blood levels are reached (not to exceed 0.2 mg/kg/day).

Availability ⬆ ⬇

(Generic available)

Tablets: 0.25 mg; 0.5 mg; 1 mg; 2 mg
Orally disintegrating tablets: 0.125 mg; 0.25 mg; 0.5 mg; 1 mg; 2 mg

Assessment ⬆ ⬇

Observe and record intensity, duration, and location of seizure activity.
Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy.
Assess need for continued treatment regularly.
Assess patient for drowsiness, unsteadiness, and clumsiness. These symptoms are dose related and most severe during initial therapy; may decrease in severity or disappear with continued or long-term therapy.
Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.
Assess risk for addiction, abuse, or misuse prior to administration and periodically during therapy.

Lab Test Considerations:

Patients on prolonged therapy should have CBC and liver function test results evaluated periodically. May cause an ↑ in serum bilirubin, AST, and ALT.
- May cause ↓ thyroidal uptake of ¹²³I, and ¹³¹I.

Toxicity and Overdose:

Therapeutic serum concentrations are 20–80 mg/mL. Flumazenil antagonizes clonazepam toxicity or overdose (may induce seizures in patients with history of seizure disorder or who are on tricyclic antidepressants).

Implementation ⬆ ⬇

Do not confuse clonazepam with alprazolam, clonidine, clozapine, clobazam, or lorazepam. Do not confuse Klonopin with clonidine.
- Institute seizure precautions for patients on initial therapy or undergoing dose manipulations.
PO: Administer with food to minimize gastric irritation. Tablets may be crushed if patient has difficulty swallowing. Administer largest dose at bedtime to avoid daytime sedation. Taper by 0.25 mg every 3 days to decrease signs and symptoms of withdrawal. Some patients may require longer taper period (months).
- Orally disintegrating tablets should be left in the package until use. Remove from the blister pouch. Do not push tablet through the blister; peel open the blister pack with dry hands and place tablet on tongue. Tablet will dissolve rapidly and be swallowed with saliva. No liquid is needed to take the orally disintegrating tablet.
Gradually taper to discontinue or reduce the dose to reduce risk of withdrawal reactions, increased seizure frequency, and status epilepticus. Taper by decreasing total daily dose on a weekly basis until discontinued. If patient develops withdrawal symptoms, pause taper or increase dose to previous tapered dose level; decrease dose more slowly. Some patients may require longer tapering period (weeks to >12 mo).

Patient/Family Teaching ⬆ ⬇

Instruct patient to take medication exactly as directed. Take missed doses within 1 hr or omit; do not double doses. Abrupt withdrawal of clonazepam may cause status epilepticus, tremors, nausea, vomiting, and abdominal and muscle cramps. Instruct patient to read the Medication Guide before starting and with each Rx refill; changes may occur.
Advise patient that clonazepam is usually prescribed for short-term use and does not cure underlying problems.
Advise patient that clonazepam is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was prescribed. Store out of sight and reach of children, and in a location not accessible by others.
Advise patient to not share medication with others.
May cause drowsiness or dizziness. Advise patient to avoid driving or other activities requiring alertness until response to drug is known.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products. Caution patient to avoid taking alcohol or other CNS depressants, including opioids, concurrently with this medication, may cause respiratory depression and overdose.
Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
Instruct patient and family to notify health care professional of unusual tiredness, bleeding, sore throat, fever, clay-colored stools, yellowing of skin, or behavioral changes. Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping; new or worse irritability; acting aggressive; being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking; other unusual changes in behavior or mood occur.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Monitor infants exposed to clonazepam during 2nd and 3rd trimester or immediately prior to or during childbirth for decreased fetal movement and/or fetal heart rate variability, "floppy infant syndrome," dependence, sedation (respiratory depression, lethargy, hypotonia) and symptoms of withdrawal (hypertonia, hyperreflexia, hypoventilation, irritability, tremors, diarrhea, vomiting, restlessness, inconsolable crying, and feeding difficulties); may occur shortly after delivery up to 3 wk after birth. Monitor breastfed infants for sedation, poor sucking, poor feeding and poor weight gain. Encourage pregnant patients to enroll in North American Antiepileptic Drug Pregnancy Registry to collect information about safety of antiepileptic drugs during pregnancy. To enroll, patients can call 1-888-233-2334 or visit http://www.aedpregnancyregistry.org/.
Patient on anticonvulsant therapy should carry identification at all times describing disease process and medication regimen.
Emphasize the importance of follow-up exams to determine effectiveness of the medication.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆ ⬇

Contr. Subst. Schedule ⬆ ⬇

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