ClonazePAM (Lexi-Drugs)

ALERT: US Boxed Warning
  Risk from concomitant use with opioids:
Pronunciation

(kloe NA ze pam)

Brand Names: US

KlonoPIN

Brand Names: Canada

APO-ClonazePAM; Clonapam; CO ClonazePAM [DSC]; DOM-ClonazePAM; DOM-ClonazePAM-R; MYLAN-ClonazePAM [DSC]; PHL-ClonazePAM [DSC]; PMS-ClonazePAM; PMS-ClonazePAM-R; PRO-ClonazePAM; RATIO-ClonazePAM [DSC]; RIVA-ClonazePAM; Rivotril; SANDOZ ClonazePAM [DSC]; TEVA-ClonazePAM

Dosing: Adult

Panic disorder: Oral: 0.25 mg twice daily; increase in increments of 0.125 to 0.25 mg twice daily every 3 days; target dose: 1 mg daily (maximum: 4 mg/day).

Discontinuation of treatment: To discontinue, treatment should be withdrawn gradually. Decrease dose by 0.125 mg twice daily every 3 days until medication is completely withdrawn.

Seizure disorders: Oral:

Initial daily dose not to exceed 1.5 mg given in 3 divided doses; may increase by 0.5 to 1 mg every third day until seizures are controlled or adverse effects seen (maximum: 20 mg/day).

Usual maintenance dose: 2 to 8 mg daily in 1 to 2 divided doses (Brodie 1997); do not exceed 20 mg/day.

Bipolar disorder, mixed or manic episodes (off-label use): Oral: 2 to 8 mg daily, in 2 to 4 divided doses; total daily doses as high as 16 mg have been studied (Bottai 1995; Chouinard 1983; Clark 1997; Edwards 1991; WFSBP [Grunze 2009]).

Burning mouth syndrome (off-label use):

Oral: Initial: 0.25 at bedtime for 1 week; increase dose by ≤0.25 mg every week; maximum dose: 3 mg daily in 3 divided doses. Note: Use should be limited (Buchanan 2008; Grushka 1998).

Topical: May administer topically with 1 mg 3 times daily (after each meal). Note: Patient should be instructed to suck on the tablet, retain saliva in mouth near the pain sites without swallowing for 3 minutes, and then expectorate saliva (Gremeau-Richard 2004).

Essential tremor (off-label use): Oral: Initial: 0.5 mg at bedtime; increase dose by 0.5 mg every 3 to 4 days; maximum dose: 6 mg daily (Biary 1987; Thompson 1984; Zesiewicz 2005; Zesiewicz 2011).

REM sleep behavior disorder (off-label use): 0.25 to 2 mg 30 minutes prior to bedtime (maximum: 4 mg 30 minutes prior to bedtime). Note: Use with caution in patients with dementia, gait disorders, or obstructive sleep apnea (Aurora 2010).

Restless leg syndrome (off-label use): Oral: Initial: 1 mg 30 minutes prior to bedtime; increase dose by 0.5 to 1 mg at weekly intervals. Doses up to 2 mg once daily have been used in clinical trials (Montagna 1984; Peled 1987; Saletu 2001). Additional data may be necessary to further define the role of clonazepam in the treatment of this condition.

Tardive dyskinesia (off-label use): Oral: Initial: 1 mg/day; adjust dosage based on response and tolerability by 1 mg/day every 3 to 4 days up to a maximum dose of 4.5 mg/day (Thaker 1990).

Tic disorders (off-label use): Oral: Initial: 0.5 mg at bedtime; adjust dose by 0.5 mg every 2 weeks based on response and tolerability. Dosing range in clinical studies was 1 to 12 mg/day (Merikangas 1985; Troung 1988).

Dosing: Geriatric

Refer to adult dosing. Initiate with low doses and observe closely.

Dosing: Renal Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Clonazepam metabolites may accumulate in patients with renal impairment.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Clonazepam undergoes hepatic metabolism. Contraindicated in patients with significant hepatic impairment.

Dosing: Pediatric

Note: If necessary to discontinue clonazepam therapy, drug should be withdrawn gradually.

Neuroirritability, agitation (palliative care): Limited data available: Infants, Children, and Adolescents: Oral:

Patient weight:

<30 kg: Initial: 0.01 to 0.03 mg/kg/day in divided doses up to 3 to 4 times daily; increase dose to desired effect up to a maximum daily dose: 0.2 mg/kg/day in 3 divided doses (Kliegman 2017; Wustoff 2007)

≥30 kg: Initial: ≤0.25 mg/dose 3 times daily; may increase by 0.5 to 1 mg/day every 3 days up to maintenance dose range: 0.05 to 0.2 mg/kg/day up to maximum daily dose: 20 mg/day (Kliegman 2017)

Seizure disorders:

Infants and Children <10 years or ≤30 kg: Oral:

Initial: 0.01 to 0.03 mg/kg/day in 2 to 3 divided doses; maximum initial daily dose: 0.05 mg/kg/day; increase by ≤0.25 to 0.5 mg every third day until seizures are controlled or adverse effects observed

Maintenance dose: 0.1 to 0.2 mg/kg/day in 3 divided doses; maximum daily dose: 0.2 mg/kg/day

Children ≥10 years or >30 kg and Adolescents: Oral:

Initial: 0.01 to 0.05 mg/kg/day in 2 or 3 divided doses; maximum initial dose: 0.5 mg/dose 3 times daily; may increase dose by 25% or by 0.5 to 1 mg every 3 to 7 days until seizures are controlled or adverse effects observed (Kliegman 2017)

Maintenance dose range: 0.05 to 0.2 mg/kg/day in 2 to 3 divided doses; maximum daily dose: 20 mg/day (Kliegman 2017)

Panic disorder: Adolescents ≥18 years: Oral: Initial: 0.25 mg twice daily; increase in increments of 0.125 to 0.25 mg twice daily every 3 days; target dose: 1 mg/day in divided doses; some patients may require higher doses up to a maximum daily dose: 4 mg/day. To discontinue, treatment should be withdrawn gradually; decrease dose by 0.125 mg twice daily every 3 days until medication is completely withdrawn.

Dosing: Renal Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Clonazepam metabolites may accumulate in patients with renal impairment.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Clonazepam undergoes hepatic metabolism. Contraindicated in patients with significant hepatic impairment.

Use: Labeled Indications

Panic disorder: Treatment of panic disorder, with or without agoraphobia.

Seizure disorders: Mono- or adjunctive therapy in the treatment of the Lennox-Gastaut syndrome (petit mal variant), akinetic, and myoclonic seizures; absence seizures (petit mal) unresponsive to succinimides.

Use: Off-Label: Adult

  Bipolar disorder, manic or mixed episodesLevel of Evidence [B, G]

Data from a meta-analysis of 5 randomized, controlled trials supports the use of clonazepam in the treatment of acute bipolar mania Ref. Additional trials may be necessary to further define the role of clonazepam in this condition.

APA guidelines for the treatment of patients with bipolar disorder suggest that the use of benzodiazepines, such as clonazepam, in sedative doses may be useful short-term as adjunctive therapy when used with traditional mood-stabilizing agents. CANMAT guidelines for the management of patients with bipolar disorder recommend against the use of benzodiazepines as monotherapy, but suggest they may be useful adjunctive therapy for the sedation of acutely agitated patients. Similarly, WFSBP guidelines for the treatment of acute mania in bipolar disorder recommend benzodiazepines as adjunctive therapy to target anxiety and insomnia in patients taking mood-stabilizing agents.

  Burning mouth syndromeLevel of Evidence [C]

Data from a prospective open-label study in patients with mouth burning without oral mucosal lesions suggest that clonazepam may be helpful in patients with this condition Ref. Additional data from a double-blind, randomized, multicenter, parallel group study using topical (buccal administration) clonazepam demonstrated improvement in pain intensity Ref. In a systematic review, clonazepam is a therapeutic option in the treatment of this condition; however, use should be limited due to the risk of benzodiazepine dependence Ref. Additional trials are necessary to further define the role of clonazepam for the treatment of this condition.

  Essential tremorLevel of Evidence [C, G]

Data from a limited number of patients studied (case series) suggest that clonazepam may be beneficial in reducing the frequency of essential tremor Ref. On the contrary, data from a small randomized, double-blind, placebo-controlled trial demonstrated that clonazepam was not an effective treatment Ref. Additional data may be necessary to further define the role of clonazepam in this condition.

Based on the American Academy of Neurology guidelines for the treatment of essential tremor, clonazepam is possibly effective for the treatment of this condition.

  Rapid eye movement (REM) sleep behavior disorderLevel of Evidence [G]

Based on the American Academy of Sleep Medicine (AASM) Best Practice Guide for the Treatment of REM Sleep Behavior Disorder (RBD), clonazepam is an effective and recommended treatment option for patients with this condition; however, it should be used with caution in patients with dementia, gait disorders, or concomitant obstructive sleep apnea Ref.

  Restless legs syndromeLevel of Evidence [C]

Data from a limited number of patients in small controlled trials suggest that clonazepam may be beneficial for the treatment of periodic limb movements and poor sleep associated with restless legs syndrome Ref. Additional data may be necessary to further define the role of clonazepam in this condition.

Based on the updated American Academy of Sleep Medicine guidelines, there are insufficient data available to recommend benzodiazepines, specifically clonazepam, for first-line treatment of RLS. Based on the EFNS/ENS/ESRS joint task force guidelines on the management of restless legs syndrome, clonazepam is probably effective for the treatment of primary RLS; however, this recommendation was based on only one open-label trial. The American Academy of Neurology (AAN) guidelines state that there is insufficient evidence to support or refute the use of clonazepam in the treatment of RLS. Access Full Off-Label Monograph

  Tardive dyskinesiaLevel of Evidence [C, G]

Data from a limited number of patients in a double-blind, randomized, placebo-controlled crossover trial suggests that clonazepam may be beneficial for the treatment of tardive dyskinesia Ref. Additional data may be necessary to further define the role of clonazepam in this condition.

Based on the American Academy of Neurology guideline for the treatment of tardive syndromes, clonazepam given for tardive dyskinesia is probably effective in decreasing tardive dyskinesia symptoms in the short-term (approximately 3 months) and is suggested for the short-term treatment of tardive dyskinesia.

  Tic disordersLevel of Evidence [C]

Data from a limited number of patients studied in a single-blind and two retrospective studies suggest that clonazepam may be beneficial for multifocal tic disorder or Tourette disorder. Additional data may be necessary to further define the role of clonazepam in these conditions. Access Full Off-Label Monograph

Level of Evidence Definitions
  Level of Evidence Scale
Clinical Practice Guidelines

Panic disorder:

American Psychiatric Association, “Practice guideline for the treatment of patients with panic disorder,” 2009

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders, First Revision,” 2008

Tardive dyskinesia:

American Academy of Neurology, “Evidence-based Guideline: Treatment of tardive syndromes,” July 2013

Tourette syndrome:

European Society for the Study of Tourette syndrome, “European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment,” 2011.

Administration: Oral

To reduce somnolence, administration of one dose at bedtime may be desirable.

Orally-disintegrating tablet: Open pouch and peel back foil on the blister; do not push tablet through foil. Use dry hands to remove tablet and place in mouth. May be swallowed with or without water. Use immediately after removing from package.

Tablet: Swallow whole with water.

Administration: Pediatric

Oral: To reduce somnolence, administration of one dose at bedtime may be desirable.

Orally disintegrating tablet: Open pouch and peel back foil on the blister; do not push tablet through foil. Use dry hands to remove tablet and place in mouth. May be swallowed with or without water. Use immediately after removing from package.

Tablet: Swallow whole with water

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 3]).

Use appropriate precautions for receiving, handling, administration, and disposal. Gloves (single) should be worn during receiving, unpacking, and placing in storage.

NIOSH recommends single gloving for administration of intact tablets or capsules. If manipulating tablets/capsules (eg, to prepare an oral suspension), NIOSH recommends double gloving, a protective gown, and preparation in a controlled device; if not prepared in a controlled device, respiratory and eye/face protection as well as ventilated engineering controls are recommended. NIOSH recommends double gloving, a protective gown, and (if there is a potential for vomit or spit up) eye/face protection for administration of an oral liquid/feeding tube administration (NIOSH 2016). Assess risk to determine appropriate containment strategy (USP-NF 2017).

Storage/Stability

Tablets: Store at 20°C to 25°C (68°F to 77°F).

Orally disintegrating tablets: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F)

Extemporaneously Prepared

A 0.1 mg/mL oral suspension may be made with tablets and one of three different vehicles (cherry syrup; a 1:1 mixture of Ora-Sweet® and Ora-Plus®; or a 1:1 mixture of Ora-Sweet® SF and Ora-Plus®). Crush six 2 mg tablets in a mortar and reduce to a fine powder. Add 10 mL of the chosen vehicle and mix to a uniform paste; mix while adding the vehicle in incremental proportions to almost 120 mL; transfer to a calibrated bottle, rinse mortar with vehicle, and add quantity of vehicle sufficient to make 120 mL. Label “shake well” and “protect from light”. Stable for 60 days when stored in amber prescription bottles in the dark at room temperature or refrigerated.

Allen LV Jr and Erickson MA 3rd, “Stability of Acetazolamide, Allopurinol, Azathioprine, Clonazepam, and Flucytosine in Extemporaneously Compounded Oral Liquids,” Am J Health Syst Pharm 1996, 53(16):1944-9.[PubMed 8862208]

Medication Patient Education with HCAHPS Considerations

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience fatigue, increased saliva, common cold symptoms, constipation, or dizziness. Have patient report immediately to prescriber shortness of breath, change in balance, confusion, severe loss of strength and energy, memory impairment, seizures, menstrual pain, nightmares, hallucinations, signs of depression (suicidal ideation, anxiety, emotional instability, or confusion), agitation, irritability, panic attacks, behavioral changes, or mood changes (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Medication Safety Issues
  Sound-alike/look-alike issues:
  Geriatric Patients: High-Risk Medication:
Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017533s058lbl.pdf, must be dispensed with this medication.

Contraindications

Hypersensitivity to clonazepam, other benzodiazepines, or any component of the formulation; significant liver disease; acute narrow-angle glaucoma

Canadian labeling: Additional contraindications (not in US labeling): Severe respiratory insufficiency; sleep apnea syndrome; myasthenia gravis

Warnings/Precautions

Concerns related to adverse effects:

• Anterograde amnesia: Benzodiazepines have been associated with anterograde amnesia (Nelson 1999).

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving); increased risk may occur with the use of multiple anticonvulsants.

• Paradoxical reactions: Paradoxical reactions, including hyperactive or aggressive behavior, have been reported with benzodiazepines; risk may be increased in adolescent/pediatric patients, geriatric patients, or patients with a history of alcohol use disorder or psychiatric/personality disorders (Mancuso 2004).

• Sleep-related activities: Hazardous sleep-related activities such as sleep-driving, cooking and eating food, and making phone calls while asleep have been noted with benzodiazepines (Dolder 2008).

• Suicidal ideation: Pooled analysis of trials involving various antiepileptics (regardless of indication) showed an increased risk of suicidal thoughts/behavior (incidence rate: 0.43% treated patients compared to 0.24% of patients receiving placebo); risk observed as early as 1 week after initiation and continued through duration of trials (most trials ≤24 weeks). Monitor all patients for notable changes in behavior that might indicate suicidal thoughts or depression; notify health care provider immediately if symptoms occur.

Disease-related concerns:

• Depression: Use caution in patients with depression, particularly if suicidal risk may be present.

• Drug abuse: Use with caution in patients with a history of drug abuse or acute alcoholism; potential for drug dependency exists. Tolerance, psychological and physical dependence may occur with prolonged use.

• Glaucoma: May be used in patients with open angle glaucoma who are receiving appropriate therapy; contraindicated in acute narrow angle glaucoma.

• Hepatic impairment: Use with caution in patients with hepatic impairment; accumulation likely to occur. Contraindicated in patients with significant hepatic impairment.

• Porphyria: Use with caution in patients with porphyria; may have a porphyrogenic effect.

• Renal impairment: Use with caution in patients with renal impairment; clonazepam metabolites are renally eliminated.

• Respiratory disease: Clonazepam may cause respiratory depression and may produce an increase in salivation; use with caution in patients with compromised respiratory function (eg, chronic obstructive pulmonary disease, sleep apnea) and in patients who have difficulty handling secretions.

Concurrent drug therapy issues:

• Concomitant use with opioids: [US Boxed Warning]: Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation.

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Debilitated patients: Use with caution in debilitated patients.

• Elderly patients: Elderly patients may be at an increased risk of death with use; risk has been found highest within the first 4 months of use in elderly dementia patients (Jennum 2015; Saarelainen 2018).

• Fall risk: Use with extreme caution in patients who are at risk of falls; benzodiazepines have been associated with falls and traumatic injury (Nelson 1999).

Other warnings/precautions:

• Appropriate use: Does not have analgesic, antidepressant, or antipsychotic properties. Worsening of seizures may occur when added to patients with multiple seizure types. Loss of anticonvulsant activity may occur (typically within 3 months of initiation); dose adjustment may be necessary. Periodically reevaluate the long-term usefulness of clonazepam for the individual patient.

• Tolerance: Clonazepam is a long half-life benzodiazepine. Duration of action after a single dose is determined by redistribution rather than metabolism. Tolerance develops to the anticonvulsant effects. It does not develop to the anxiolytic effects (Vinkers 2012). Chronic use of this agent may increase the perioperative benzodiazepine dose needed to achieve desired effect.

• Withdrawal: Rebound or withdrawal symptoms may occur following abrupt discontinuation or large decreases in dose. Use caution when reducing dose or withdrawing therapy; decrease slowly and monitor for withdrawal symptoms. Flumazenil may cause withdrawal in patients receiving long-term benzodiazepine therapy (Brogden 1988).

Geriatric Considerations

Hepatic clearance may be decreased allowing accumulation of active drug. Also, metabolites of clonazepam are renally excreted and may accumulate in the elderly as renal function declines with age.

Pregnancy Considerations

Clonazepam crosses the placenta. Teratogenic effects have been observed with some benzodiazepines; however, additional studies are needed. The incidence of premature birth and low birth weights may be increased following maternal use of benzodiazepines; hypoglycemia and respiratory problems in the neonate may occur following exposure late in pregnancy. Neonatal withdrawal symptoms may occur within days to weeks after birth and “floppy infant syndrome” (which also includes withdrawal symptoms) has been reported with some benzodiazepines, including clonazepam (Bergman 1992; Iqbal 2002; Wikner 2007). A combination of factors influences the potential teratogenicity of anticonvulsant therapy. When treating pregnant females with epilepsy, monotherapy with the lowest effective dose and avoidance medications known to have a high incidence of teratogenic effects is recommended (Harden 2009; Wlodarczyk 2012). When treating pregnant females with panic disorder, psychosocial interventions should be considered prior to pharmacotherapy (APA 2009).

Patients exposed to clonazepam during pregnancy are encouraged to enroll themselves into the AED Pregnancy Registry by calling 1-888-233-2334. Additional information is available at www.aedpregnancyregistry.org.

Breast-Feeding Considerations

Clonazepam is present in breast milk.

The relative infant dose (RID) of clonazepam is 2.8% when calculated using the highest breast milk concentration from a case report and compared to a weight-adjusted maternal dose of 4 mg/day.

In general, breastfeeding is considered acceptable when an RID of a medication is <10% (Anderson 2016; Ito 2000). However, some sources note breastfeeding should only be considered if the RID is <5% for psychotropic agents (Larsen 2015).

The RID of clonazepam was calculated using a milk concentration of 0.0107 mcg/mL, providing an estimated daily infant dose via breast milk of 1.6 mcg/kg/day. This milk concentration was obtained following maternal administration of clonazepam 2 mg twice daily during pregnancy and after delivery; milk samples were obtained on days 2 to 4 postpartum (Söderman 1988). Slightly higher milk concentrations (0.013 mcg/mL) were noted in a second report. The mother was taking clonazepam throughout pregnancy (dose not specified); milk sampling began 72 hours after delivery (Fisher 1985). Clonazepam was detected in the serum of the breastfeeding infants (Fisher 1985; Söderman 1988) and concentrations may have been influenced not only by breast milk but also by in utero exposure.

Apnea, CNS depression, hypotonia, and somnolence have been reported in infants exposed to clonazepam via breast milk (Fisher 1985; Kelly 2012; Soussan 2014). In a review of females taking various doses of clonazepam (range: 0.5 to 2 mg/day) during pregnancy and postpartum (n=10) or only postpartum (n=1), clonazepam was measurable in the serum of two infants; however, adverse events were not reported (Birnbaum 1999).

Clonazepam has a long half-life and may accumulate in the breastfed infant, especially preterm infants or those exposed to chronic maternal doses (Davanzo 2013). A single maternal dose may be compatible with breastfeeding (WHO 2002). If chronic use of a benzodiazepine is needed in breastfeeding females, use of shorter acting agents is preferred (Davanzo 2013; Veiby 2015; WHO 2002). Infants of females using medications for seizure disorders should be monitored for drowsiness, decreased feeding, and poor weight gain (Veiby 2015). According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.

Briggs’ Drugs in Pregnancy & Lactation
Adverse Reactions

Reactions reported in patients with seizure disorder, unless otherwise noted. Frequency not always defined.

>10%: Central nervous system: Drowsiness (seizure disorder: ~50%; panic disorder: 26% to 50%), ataxia (seizure disorder: ~30%; panic disorder: 1% to 9%), behavioral problems (seizure disorder: ~25%), dizziness (panic disorder: 5% to 12%)

1% to 10%:

Central nervous system: Fatigue (panic disorder: 6% to 9%), depression (panic disorder: 6% to 8%), memory impairment (panic disorder: 4% to 5%), nervousness (panic disorder: 3% to 4%), dysarthria (panic disorder: ≤4%), reduced intellectual ability (panic disorder: ≤4%), emotional lability (panic disorder: 2%), confusion (panic disorder: ≤2%), delayed ejaculation (panic disorder ≤2%)

Endocrine & metabolic: Decreased libido (panic disorder: ≤3%)

Gastrointestinal: Constipation (panic disorder: 3% to 5%), decreased appetite (panic disorder: 3%), abdominal pain (panic disorder: 2%)

Genitourinary: Dysmenorrhea (panic disorder: 3% to 6%), vaginitis (panic disorder: 2% to 4%), impotence (panic disorder: ≤3%), urinary tract infection (panic disorder: ≤2%), urinary frequency (panic disorder: 1% to 2%)

Hypersensitivity: Hypersensitivity (panic disorder: 2% to 4%)

Neuromuscular & skeletal: Myalgia (panic disorder: 2% to 4%)

Ophthalmic: Blurred vision (panic disorder: 2% to 3%)

Respiratory: Upper respiratory tract infection (panic disorder: 6% to 10%), sinusitis (panic disorder: 4% to 8%), influenza (panic disorder: 4% to 5%), cough (panic disorder: ≤4%), rhinitis (panic disorder: 2% to 4%), pharyngitis (panic disorder: 2% to 3%), bronchitis (panic disorder: 2%)

Frequency not defined:

Cardiovascular: Edema (ankle or facial), palpitations

Central nervous system: Amnesia, aphonia, choreiform movements, coma, glassy-eyed appearance, hallucination, headache, hemiparesis, hypotonia, hysteria, insomnia, myasthenia, psychosis, slurred speech, vertigo

Dermatologic: Alopecia, skin rash

Endocrine & metabolic: Dehydration, hirsutism, increased libido, weight gain, weight loss

Gastrointestinal: Anorexia, coated tongue, diarrhea, encopresis, gastritis, gingival pain, increased appetite, nausea, xerostomia

Genitourinary: Dysuria, nocturia, urinary incontinence, urinary retention

Hematologic & oncologic: Anemia, eosinophilia, leukopenia, lymphadenopathy, thrombocytopenia

Hepatic: Hepatomegaly, increased serum alkaline phosphatase (transient), increased serum transaminases (transient)

Neuromuscular & skeletal: Dysdiadochokinesia, tremor

Ophthalmic: Abnormal eye movements, diplopia, nystagmus

Respiratory: Chest congestion, dyspnea, respiratory depression, rhinorrhea, upper respiratory complaint (hypersecretion)

Miscellaneous: Fever, paradoxical reactions (including aggressive behavior, agitation, anxiety excitability, hostility, irritability, nervousness, nightmares, sleep disturbance, vivid dreams), physical health deterioration

<1%, postmarketing, and/or case reports (any indication): Abdominal distress, abnormal behavior (increased oppositional behavior), accidental injury, acne flare, ageusia, aggressive behavior, alcohol intoxication, anxiety, apathy, arthralgia, back pain, bladder dysfunction, bone fracture, burn, burning sensation of skin, candidiasis, cellulitis, chest pain, contact dermatitis, cystitis, depersonalization, dermal hemorrhage, dermatological reaction, disinhibition (organic), dyspepsia, ejaculatory disorder, epistaxis, exacerbation of asthma, excitement, excoriation, eye irritation, falling, flatulence, flushing, foot pain, frequent bowel movements, fungal infection, gastric distress, gout, heartburn, heavy headedness, hemorrhoids, herpes simplex infection, hoarseness, hordeolum, hyperactivity, hypertonia, hypoesthesia, hunger, illusion, increased dream activity, increased thirst, infectious mononucleosis, irregular menses, irritability, jaw pain, knee effusion, knee pain, lack of concentration, leg pain, leg thrombophlebitis, local inflammation, lower back pain, malaise, mastalgia, migraine, motion sickness, orthostatic hypotension, otalgia, otitis, pain, paresis, paresthesia, pedal edema, pelvic pain, periorbital edema, pleurisy, pneumonia, polyuria, pruritus, pustular rash, shivering, shoulder pain, sialorrhea, sleep disorder, slowed reaction time, sneezing, sprain, strain, streptococcal infection, suicidal ideation, suicidal tendencies, tendonitis, tongue edema, toothache, twitching, twitching of eye, urinary tract hemorrhage, urine discoloration, viral infection, visual disturbance, visual field defect, withdrawal syndrome, xeroderma, xerophthalmia, yawning

Allergy and Idiosyncratic Reactions
Toxicology
Metabolism/Transport Effects

Substrate of CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions 

Alcohol (Ethyl): CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). Risk C: Monitor therapy

Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Azelastine (Nasal): CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). Risk X: Avoid combination

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Risk D: Consider therapy modification

Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromopride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine patches (Butrans brand) at 5 mcg/hr in adults when used with other CNS depressants.Risk D: Consider therapy modification

Cannabidiol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Cannabis: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CloZAPine: Benzodiazepines may enhance the adverse/toxic effect of CloZAPine. Management: Consider decreasing the dose of (or possibly discontinuing) benzodiazepines prior to initiating clozapine. Risk D: Consider therapy modification

CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Risk C: Monitor therapy

Cobicistat: May increase the serum concentration of ClonazePAM. Risk C: Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Cosyntropin: May enhance the hepatotoxic effect of ClonazePAM. Risk C: Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Risk D: Consider therapy modification

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors). Risk D: Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Risk D: Consider therapy modification

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Doxylamine: May enhance the CNS depressant effect of CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended. Risk C: Monitor therapy

Dronabinol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Droperidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs. Risk D: Consider therapy modification

Duvelisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Risk D: Consider therapy modification

Esketamine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Risk D: Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Fosnetupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Fosphenytoin: May decrease the serum concentration of ClonazePAM. Clonazepam may also alter concentrations of Phenytoin (active metabolite of Fosphenytoin). Risk C: Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

HYDROcodone: CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.Risk D: Consider therapy modification

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Kava Kava: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

Larotrectinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs. Risk C: Monitor therapy

Lorlatinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Avoid concurrent use of lorlatinib with any CYP3A4 substrates for which a minimal decrease in serum concentrations of the CYP3A4 substrate could lead to therapeutic failure and serious clinical consequences. Risk D: Consider therapy modification

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Melatonin: May enhance the sedative effect of Benzodiazepines. Risk C: Monitor therapy

Methadone: Benzodiazepines may enhance the CNS depressant effect of Methadone. Management: Clinicians should generally avoid concurrent use of methadone and benzodiazepines when possible; any combined use should be undertaken with extra caution. Risk D: Consider therapy modification

Methotrimeprazine: CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. Risk D: Consider therapy modification

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Risk D: Consider therapy modification

Minocycline: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Mirtazapine: CNS Depressants may enhance the CNS depressant effect of Mirtazapine. Risk C: Monitor therapy

Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Risk D: Consider therapy modification

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

OLANZapine: May enhance the adverse/toxic effect of Benzodiazepines. Management: Avoid concomitant use of parenteral benzodiazepines and IM olanzapine due to risks of additive adverse events (e.g., cardiorespiratory depression). Olanzapine prescribing information provides no specific recommendations regarding oral administration. Risk X: Avoid combination

Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.Risk D: Consider therapy modification

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination

Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. Risk D: Consider therapy modification

Phenytoin: May decrease the serum concentration of ClonazePAM. Clonazepam may also alter concentrations of Phenytoin. Risk C: Monitor therapy

Piribedil: CNS Depressants may enhance the CNS depressant effect of Piribedil. Risk C: Monitor therapy

Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Risk D: Consider therapy modification

Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy

ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy

Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy

Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Selective Serotonin Reuptake Inhibitors: CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Risk C: Monitor therapy

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Sodium Oxybate: Benzodiazepines may enhance the CNS depressant effect of Sodium Oxybate. Risk X: Avoid combination

St John’s Wort: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Risk D: Consider therapy modification

Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Risk D: Consider therapy modification

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Tapentadol: May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Teduglutide: May increase the serum concentration of Benzodiazepines. Risk C: Monitor therapy

Tetrahydrocannabinol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Tetrahydrocannabinol and Cannabidiol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination

Theophylline Derivatives: May diminish the therapeutic effect of Benzodiazepines. Risk D: Consider therapy modification

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Trimeprazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Vigabatrin: May enhance the CNS depressant effect of ClonazePAM. Vigabatrin may increase the serum concentration of ClonazePAM. Risk C: Monitor therapy

Yohimbine: May diminish the therapeutic effect of Antianxiety Agents. Risk C: Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification

Monitoring Parameters

CBC, liver and renal function tests (periodically with long-term therapy) suicidality (eg, suicidal thoughts, depression, behavioral changes)

Reference Range

Relationship between serum concentration and seizure control is not well established. Therapeutic doses have been associated with serum concentrations of ~15 to 70 ng/mL (Pataslos 2008)

Advanced Practitioners Physical Assessment/Monitoring

Assess for signs of CNS depression. Assess history of addiction; long-term use can result in dependence, abuse, or tolerance; periodically evaluate need for continued use. For inpatient use, institute safety measures to prevent falls. Taper dosage slowly when discontinuing. Teach patient seizure precautions (if administered for seizures).

Nursing Physical Assessment/Monitoring

Assess for signs of CNS depression (sedation, dizziness, confusion, or ataxia). Assess history of addiction; long-term use can result in dependence, abuse, or tolerance; periodically evaluate need for continued use. For inpatient use, institute safety measures to prevent falls. Taper dosage slowly when discontinuing. Teach patient seizure precautions (if administered for seizures).

Controlled Substance

C-IV

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

KlonoPIN: 0.5 mg [scored; contains fd&c yellow #6 aluminum lake]

KlonoPIN: 1 mg [contains fd&c blue #1 aluminum lake, fd&c blue #2 aluminum lake]

KlonoPIN: 2 mg

Generic: 0.5 mg, 1 mg, 2 mg

Tablet Disintegrating, Oral:

Generic: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Rivotril: 0.5 mg, 2 mg

Generic: 0.25 mg, 0.5 mg, 1 mg, 2 mg

Anatomic Therapeutic Chemical (ATC) Classification
  • N03AE01
Generic Available (US)

Yes

Pricing: US

Tablet, orally-disintegrating (clonazePAM Oral)

0.125 mg (per each): $1.30

0.25 mg (per each): $1.30

0.5 mg (per each): $1.30

1 mg (per each): $1.48

2 mg (per each): $2.05

Tablets (clonazePAM Oral)

0.5 mg (per each): $0.71 – $0.80

1 mg (per each): $0.81 – $0.91

2 mg (per each): $1.13 – $1.24

Tablets (KlonoPIN Oral)

0.5 mg (per each): $3.06

1 mg (per each): $3.49

2 mg (per each): $4.84

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer’s AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

The exact mechanism is unknown, but believed to be related to its ability to enhance the activity of GABA; suppresses the spike-and-wave discharge in absence seizures by depressing nerve transmission in the motor cortex.

Pharmacodynamics/Kinetics

Onset of action: ~20 to 40 minutes (Hanson 1972)

Duration: Infants and young children: 6 to 8 hours (Hanson 1972); Adults: ≤12 hours (Hanson 1972)

Absorption: Rapidly and completely absorbed

Distribution: Children: Vd: 1.5 to 3 L/kg (Walson 1996); Adults: Vd: 1.5 to 6.4 L/kg (Walson 1996)

Protein binding: ~85%

Metabolism: Extensively hepatic via glucuronide and sulfate conjugation; undergoes nitroreduction to 7-aminoclonazepam, followed by acetylation to 7-acetamidoclonazepam; nitroreduction and acetylation are via cytochrome P450 enzyme system; metabolites undergo glucuronide and sulfate conjugation

Bioavailability: ~90%

Half-life elimination: Children: 22 to 33 hours (Walson 1996); Adults: 17 to 60 hours (Walson 1996)

Time to peak, serum: 1 to 4 hours

Excretion: Urine (<2% as unchanged drug); metabolites excreted as glucuronide or sulfate conjugates

Dental Use

Burning mouth syndrome

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

Key adverse event(s) related to dental treatment: Xerostomia and changes in salivation (normal salivary flow resumes upon discontinuation), gum soreness, and coated tongue.

Effects on Bleeding

No information available to require special precautions

Dental Usual Dosing

Burning mouth syndrome (off-label use): Adults: Oral: 0.25-3 mg/day in 2 divided doses, in morning and evening

FDA Approval Date
June 04, 1975
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US Department of Health and Human Services; Centers for Disease Control and Prevention; National Institute for Occupational Safety and Health. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2016. http://www.cdc.gov/niosh/topics/antineoplastic/pdf/hazardous-drugs-list_2016-161.pdf. Updated September 2016. Accessed October 5, 2016.

Veiby G, Bjørk M, Engelsen BA, Gilhus NE. Epilepsy and recommendations for breastfeeding. Seizure. 2015;28:57-65.[PubMed 25837494]

Vinkers CH, Olivier B. Mechanisms Underlying Tolerance after Long-Term Benzodiazepine Use: A Future For Subtype-Selective GABA(A) Receptor Modulators? Adv Pharmacol Sci. 2012;2012:416864.[PubMed 22536226]

Walson PD, Edge JH. Clonazepam disposition in pediatric patients. Ther Drug Monit. 1996;18(1):1-5.[PubMed 8848810]

Wikner BN, Stiller CO, Bergman U, Asker C , Källén B. Use of benzodiazepines and benzodiazepine receptor agonists during pregnancy: neonatal outcome and congenital malformations. Pharmacoepidemiol Drug Saf. 2007;16(11):1203-1210.[PubMed 17894421]

Winkelman JW, Armstrong MJ, Allen RP, et al. Practice guideline summary: treatment of restless legs syndrome in adults: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2016;87(24):2585-2593.[PubMed 27856776]

Wlodarczyk BJ, Palacios AM, George TM, Finnell RH. Antiepileptic drugs and pregnancy outcomes. Am J Med Genet A. 2012;158A(8):2071-2090.[PubMed 22711424]

World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the eleventh WHO model list of essential drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/

Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15(1):1-44.[PubMed 23237061]

Zesiewicz TA, Elble R, Louis ED, et al, “Practice Parameter: Therapies for Essential Tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology,” Neurology, 2005, 64(12):2008-20.[PubMed 15972843]

Zesiewicz TA, Elble R, Louis ED, et al, “Evidence-Based Guideline Update: Treatment of Essential Tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology,” Neurology, 2011, 77(19):1752-5.[PubMed 22013182]

Brand Names: International

Aklonil (TR); Amotril (AE, BH, CY, EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE); Antaspan (VN); Antelepsin (HU); Anzatax (PE); Apetryl (EG); Clonapilep (MX); Clonaril (TH); Clonatril (JO); Clonatryl (CO); Clonazepamum (HU); Clonex (IL); Clonium (BD); Clonofax (CR, DO, GT, HN, NI, PA, SV); Clonopam (TW); Clonotril (CY, HK, MT, PH, SG, TR); Clozapam (BD); Clozer (MX); Convolsil (TH); Coquan (CO); Iktorivil (SE); Jing Kang (CN); Kenoket (MX); Klozepam (EG); Kriadex (MX); Leptic (BD); Lonazep (IN); Naza (LK); Neuryl (EC, LK); Paxam (AU, NZ); Povanil (TH); Ravotril (CL); Riklona (ID); Rivatril (FI); Rivopam (SG); Rivoram (JO); Rivotril (AE, AR, AT, AU, BD, BE, BG, BH, BO, BR, CH, CR, CY, CZ, DE, DK, DO, EC, EE, ES, FR, GH, GR, GT, HK, HN, HR, HU, IL, IQ, IR, IS, IT, JO, JP, KE, KR, KW, LB, LK, LT, LU, LY, MX, MY, NI, NL, NO, NZ, OM, PA, PE, PH, PK, PL, PR, PT, PY, QA, RO, SA, SG, SI, SK, SV, SY, TR, TW, TZ, UG, UY, VE, VN, YE, ZM, ZW); Ronatril (EG); Valpax (CL, PY); Xetril (BD); Zepanc (TW); Zymanta (MX)

Clonazepam (Patient Education – Adult Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(kloe NA ze pam)

Brand Names: US

KlonoPIN

Brand Names: Canada

Clonapam; Rivotril

Warning
  • This drug is a benzodiazepine. The use of a benzodiazepine drug along with opioid drugs has led to very bad side effects. Side effects that have happened include slowed or trouble breathing and death. Opioid drugs include drugs like codeine, oxycodone, and morphine. Opioid drugs are used to treat pain and some are used to treat cough. Talk with the doctor.
  • If you are taking this drug with an opioid drug, get medical help right away if you feel very sleepy or dizzy; if you have slow, shallow, or trouble breathing; or if you pass out. Caregivers or others need to get medical help right away if the patient does not respond, does not answer or react like normal, or will not wake up.
What is this drug used for?
  • It is used to treat seizures.
  • It is used to treat panic attacks.
  • It may be given to you for other reasons. Talk with the doctor.
What do I need to tell my doctor BEFORE I take this drug?
  • If you have an allergy to clonazepam or any other part of this drug.
  • If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If you have any of these health problems: Glaucoma or liver disease.
  • If you are breast-feeding. Do not breast-feed while you take this drug.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.
What are some things I need to know or do while I take this drug?
  • All products:
  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists.
  • This drug may be habit-forming with long-term use.
  • Do not stop taking this drug all of a sudden without calling your doctor. You may have a greater risk of side effects. If you need to stop this drug, you will want to slowly stop it as ordered by your doctor.
  • Have your blood work checked if you are on this drug for a long time. Talk with your doctor.
  • Avoid driving and doing other tasks or actions that call for you to be alert until you see how this drug affects you.
  • If you have had seizures in the past, this drug may cause you to pass out. Use with care. Do not do activities that may be unsafe to you or others if you pass out, like driving or swimming.
  • If you have lung disease, talk with your doctor. You may be more sensitive to this drug.
  • Avoid drinking alcohol while taking this drug.
  • Talk with your doctor before you use other drugs and natural products that slow your actions.
  • Talk with your doctor if this drug stops working well. Do not take more than ordered.
  • If you are taking phenytoin, talk with your doctor. You may need to have your blood work checked more closely while you are taking it with this drug.
  • If you are 65 or older, use this drug with care. You could have more side effects.
  • This drug may cause harm to the unborn baby if you take it while you are pregnant, especially in the first trimester.
  • Taking this drug late in pregnancy may raise the chance of breathing or feeding problems, low body temperature, or withdrawal symptoms in the newborn. Talk with the doctor.
  • If you are pregnant or you get pregnant while taking this drug, call your doctor right away.
  • For seizures:
  • Do not change the dose or stop this drug. This could cause seizures. Talk with your doctor.
  • Oral-disintegrating tablet:
  • If you have phenylketonuria (PKU), talk with your doctor. Some products have phenylalanine.
What are some side effects that I need to call my doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
  • For all uses of this drug:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Shortness of breath.
  • Change in balance.
  • Feeling confused.
  • Feeling very tired or weak.
  • Memory problems or loss.
  • Period (menstrual) pain.
  • Bad dreams.
  • Hallucinations (seeing or hearing things that are not there).
  • Patients who take this drug may be at a greater risk of having thoughts or actions of suicide. The risk may be greater in people who have had these thoughts or actions in the past. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur.
  • For seizures:
  • If seizures are new or worse after starting this drug.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
  • Feeling sleepy.
  • Constipation.
  • More saliva.
  • Dizziness.
  • Feeling tired or weak.
  • Signs of a common cold.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best taken?
  • Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.
  • Tablets:
  • Swallow whole with a full glass of water.
  • Oral-disintegrating tablet:
  • Be sure your hands are dry before you touch this drug.
  • Place on your tongue and let it dissolve. Water is not needed. Do not swallow it whole. Do not chew, break, or crush it.
  • If the tablets come in a foil blister, do not push the tablet out of the foil when opening. Use dry hands to take it from the foil.
What do I do if I miss a dose?
  • Take a missed dose as soon as you think about it.
  • If it is close to the time for your next dose, skip the missed dose and go back to your normal time.
  • Do not take 2 doses at the same time or extra doses.
How do I store and/or throw out this drug?
  • All products:
  • Store at room temperature.
  • Store in a dry place. Do not store in a bathroom.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
  • Oral-disintegrating tablet:
  • Protect from light.
  • If this drug comes in a foil pouch, store in the foil pouch until ready for use.
  • Use oral-disintegrating tablet right after opening. Throw away any part of opened pouch that is not used.
General drug facts
  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
  • Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.
Clonazepam (Patient Education – Pediatric Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(kloe NA ze pam)

Brand Names: US

KlonoPIN

Brand Names: Canada

Clonapam; Rivotril

Warning
  • This drug is a benzodiazepine. The use of a benzodiazepine drug along with opioid drugs has led to very bad side effects. Side effects that have happened include slowed or trouble breathing and death. Opioid drugs include drugs like codeine, oxycodone, and morphine. Opioid drugs are used to treat pain and some are used to treat cough. Talk with the doctor.
  • If your child is taking this drug with an opioid drug, get medical help right away if your child feels very sleepy or dizzy; if your child has slow, shallow, or trouble breathing; or if your child passes out. Get medical help right away if your child does not respond, does not answer or react like normal, or will not wake up.
What is this drug used for?
  • It is used to treat seizures.
  • It is used to treat panic attacks.
  • It may be given to your child for other reasons. Talk with the doctor.
What do I need to tell the doctor BEFORE my child takes this drug?
  • If your child has an allergy to this drug or any part of this drug.
  • If your child is allergic to any drugs like this one or any other drugs, foods, or other substances. Tell the doctor about the allergy and what signs your child had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If your child has any of these health problems: Glaucoma or liver disease.
  • If your child is breast-feeding a baby:
  • Be sure your child does not breast-feed a baby while taking this drug.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.
What are some things I need to know or do while my child takes this drug?
  • All products:
  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • This drug may be habit-forming with long-term use.
  • Do not stop giving this drug to your child all of a sudden without calling the doctor. Your child may have a greater risk of side effects. If your child needs to stop this drug, you will want to slowly stop it as told by the doctor.
  • Have your child’s blood work checked if he/she is on this drug for a long time. Talk with your child’s doctor.
  • If your child has lung disease, talk with the doctor. He/she may be more sensitive to this drug.
  • Alcohol may interact with this drug. Be sure your child does not drink alcohol.
  • Talk with the doctor before giving your child other drugs and natural products that may slow your child’s actions.
  • Have your child avoid tasks or actions that call for alertness until you see how this drug affects your child. These are things like riding a bike, playing sports, or using items such as scissors, lawnmowers, electric scooters, toy cars, or motorized vehicles.
  • If your child has had seizures in the past, this drug may cause your child to pass out. Use with care. Be sure your child avoids activities that may be unsafe for your child or others if your child passes out, like swimming.
  • Talk with your child’s doctor if this drug stops working well. Do not give more than ordered.
  • If your child is taking phenytoin, talk with the doctor. Your child may need to have blood work checked more closely while taking it with this drug.
  • If your child is pregnant:
  • This drug may cause harm to the unborn baby if your child takes it during pregnancy, especially in the first trimester.
  • Taking this drug late in pregnancy may raise the chance of breathing or feeding problems, low body temperature, or withdrawal symptoms in the newborn. Talk with the doctor.
  • If your child is pregnant or gets pregnant while taking this drug, call the doctor right away.
  • For seizures:
  • Do not change the dose or stop your child’s drug. This could cause seizures. Talk with your child’s doctor.
  • Oral-disintegrating tablet:
  • If your child has phenylketonuria (PKU), talk with your child’s doctor. Some products have phenylalanine.
What are some side effects that I need to call my child’s doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:
  • For all uses of this drug:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Change in balance.
  • Feeling confused.
  • Feeling very tired or weak.
  • Shortness of breath.
  • Memory problems or loss.
  • Period (menstrual) pain.
  • Bad dreams.
  • Hallucinations (seeing or hearing things that are not there).
  • Patients who take this drug may be at a greater risk of having thoughts or actions of suicide. The risk may be greater in people who have had these thoughts or actions in the past. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur.
  • For seizures:
  • If seizures are new or worse after starting this drug.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:
  • Feeling sleepy.
  • Constipation.
  • More saliva.
  • Dizziness.
  • Feeling tired or weak.
  • Signs of a common cold.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best given?
  • Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.
  • Tablets:
  • Have your child swallow whole with a full glass of water.
  • Oral-disintegrating tablet:
  • Be sure your hands are dry before you touch this drug.
  • Place on your child’s tongue and let it dissolve. Water is not needed. Do not let your child swallow it whole. Do not let your child chew, break, or crush it.
  • If the tablets come in a foil blister, do not push the tablet out of the foil when opening. Use dry hands to take it from the foil.
What do I do if my child misses a dose?
  • Give a missed dose as soon as you think about it.
  • If it is close to the time for your child’s next dose, skip the missed dose and go back to your child’s normal time.
  • Do not give 2 doses at the same time or extra doses.
How do I store and/or throw out this drug?
  • All products:
  • Store at room temperature.
  • Store in a dry place. Do not store in a bathroom.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
  • Oral-disintegrating tablet:
  • Protect from light.
  • If this drug comes in a foil pouch, store in the foil pouch until ready for use.
  • Use oral-disintegrating tablet right after opening. Throw away any part of opened pouch that is not used.
General drug facts
  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Keep a list of all your child’s drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your child’s doctor.
  • Talk with your child’s doctor before giving your child any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.