clonazepam

(kloe na' ze pam)

Apo-Clonazepam (CAN), Clonapam (CAN), Gen-Clonazepam (CAN),
Klonopin, Klonopin Wafers, Rivotril (CAN)

Pregnancy Category D
Controlled Substance C-IV

Drug classes
Benzodiazepine
Antiepileptic

Therapeutic actions
Exact mechanisms not understood; benzodiazepines potentiate the effects of GABA, an
inhibitory neurotransmitter.

Indications
• Used alone or as adjunct in treatment of Lennox-Gastaut syndrome (petit mal
variant), akinetic and myoclonic seizures; may be useful in patients with absence
(petit mal) seizures who have not responded to succinimides; up to 30% of
patients show loss of effectiveness of drug, often within 3 mo of therapy (may
respond to dosage adjustment)
• Unlabeled uses: Treatment of panic attacks, periodic leg movements during sleep,
hypokinetic dysarthria, acute manic episodes, multifocal tic disorders, adjunct
treatment of schizophrenia, neuralgias

Contraindications and cautions

• Contraindicated with hypersensitivity to benzodiazepines, psychoses, acute
narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with
depression of vital signs; pregnancy (risk of congenital malformations, neonatal
withdrawal syndrome), labor and delivery ("floppy infant" syndrome), lactation
(infants become lethargic and lose weight).
• Use cautiously with impaired liver or kidney function, debilitation.

Available forms
Tablets—0.5, 1, 2 mg; orally disintegrating tablets—0.125, 0.25, 0.5, 1, 2 mg

Dosages
Individualize dosage; increase dosage gradually to avoid adverse effects; drug is available
only in oral dosage forms.
ADULTS
Initial dose should not exceed 1.5 mg/day PO divided into three doses; increase in
increments of 0.5–1 mg PO every 3 days until seizures are adequately controlled or until
side effects preclude further increases. Maximum recommended dosage is 20 mg/day.
PEDIATRIC PATIENTS > 10 YR OR 30 KG
Initially, 0.01–0.03 mg/kg/day PO; do not exceed 0.05 mg/kg/day PO, given in two or
three doses. Increase dosage by not more than 0.25–0.5 mg every third day until a daily
maintenance dose of 0.1–0.2 mg/kg has been reached, unless seizures are controlled by
lower dosage or side effects preclude increases. Whenever possible, divide daily dose
into three equal doses, or give largest dose hs.

Pharmacokinetics
Route Onset Peak Duration
Oral Varies 1–2 hr Weeks

Metabolism: Hepatic; T1/2: 18–50 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

Adverse effects
• CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy,
fatigue, light-headedness, disorientation, anger, hostility, episodes of mania and
hypomania, restlessness, confusion, crying, delirium, headache, slurred speech,
dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness,
difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal
symptoms; mild paradoxical excitatory reactions during first 2 weeks of
treatment
• CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension,
palpitations, edema
• Dermatologic: Urticaria, pruritus, rash, dermatitis
• EENT: Visual and auditory disturbances, diplopia, nystagmus, depressed hearing,
nasal congestion
• GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting,
difficulty in swallowing, gastric disorders, hepatic dysfunction, encoporesis
• GU: Incontinence, urinary retention, changes in libido, menstrual irregularities
• Hematologic: Elevations of blood enzymes—LDH, alkaline phosphatase, AST,
ALT; blood dyscrasias: agranulocytosis, leukopenia
• Other: Hiccups, fever, diaphoresis, paresthesias, muscular disturbances,
gynecomastia. Drug dependence with withdrawal syndrome when drug is
discontinued; more common with abrupt discontinuation of higher dosage used
for longer than 4 mo.

Interactions
Drug-drug
• Increased CNS depression with alcohol
• Increased effect with cimetidine, disulfiram, omeprazole, hormonal contraceptives
• Decreased effect with theophylline
• Risk of increased digoxin levels and toxicity; monitor patient carefully

Nursing considerations
CLINICAL ALERT!
Name confusion has been reported between Klonopin (clonazepam) and
clonidine; use caution.
Assessment
• History: Hypersensitivity to benzodiazepines; psychoses; acute narrow-angle
glaucoma; shock; coma; acute alcoholic intoxication; pregnancy; lactation;
impaired liver or kidney function, debilitation.
• Physical: Skin color, lesions; T; orientation, reflexes, affect, ophthalmologic
exam; P, BP; R, adventitious sounds; liver evaluation, abdominal exam, bowel
sounds, normal output; CBC, liver and renal function tests.

Interventions
• Monitor addiction-prone patients carefully because of their predisposition to
habituation and drug dependence.
• Monitor liver function and blood counts periodically in patients on long-term
therapy.
• Taper dosage gradually after long-term therapy, especially in epileptic patients;
substitute another antiepileptic.
• Monitor patient for therapeutic drug levels: 20–80 ng/mL.
• Arrange for patient to wear medical alert ID indicating epilepsy and drug therapy.

Teaching points
• Take drug exactly as prescribed; do not stop taking drug (long-term therapy)
without consulting health care provider.
• Avoid alcohol, sleep-inducing, or over-the-counter drugs.
• Avoid pregnancy; serious adverse effects can occur. Use of barrier contraceptives
is advised while taking this drug.
• These side effects may occur: Drowsiness, dizziness (may become less
pronounced; avoid driving or engaging in other dangerous activities); GI upset
(take drug with food); fatigue; dreams; crying; nervousness; depression,
emotional changes; bed-wetting, urinary incontinence.
• Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions,
difficulty voiding, palpitations, swelling in the extremities.

Adverse effects in Italic are most common; those in Bold are life-threatening.