Question for Ryan - Clonazepam

[Pa1965]

I've been taking 1.5 mgs BID Clonazepam (generic) for the past 11 years for severe panic disorder.  It's been the best drug for me with no side effects while keeping the attacks at bay for all this time.  My original doctor reassured me I would not develop a tolerance to it.  He said that once my dosage was established, no further increases would be needed in the case of treatment for panic disorder.  He did state that I would be physically dependent on it, which is different than tolerance, but since I have to be on it the rest of my life anyway, that doesn't matter, he stated.

A few weeks ago, I had some attacks break through for the first time, although, not full out attacks thanks to the medication.  I was concerned, however, as to why this happened all of a sudden when I've been doing so well for so long on the same dosage.  My new doctor wanted to increase my dosage up to 3 mgs per day (1.5 mgs BID) and add Paxil CR (which made me sick so I stopped after one dosage).  He didn't mention anything about going up slow, but I knew to do so with all of the research I have done over the years along with my past history of starting the medication years ago.  I made it to 2.5 mgs and haven't gone up any further as sedation is quite heavy and the attacks are now gone; however, some anxiety is still there which is quite odd since they seem to go hand-in-hand.

I would like to come back down to my usual maintenance dose of 2 mgs per day to see if I'll be okay now in case the reason for the attacks was just a bump in the roadway.  I have only been on this increased dosage of .5 mgs extra per day for 16 days now.  Being that it hasn't been that long for the extra dosage, would it be possible to just drop it back to my original 2 mgs, or should I still wean that .5 mgs down (16 weeks) until I get to my regular 2 mgs daily dosage again?  I know if I was going to go off of it completely, I would have to definitely wean, but this is a bit of a different circumstance, I think.

Also, after the experience I had with Paxil CR and a couple others in the past, I'd much rather stay away from those.  Clonazepam has been perfect for me.  Is it possible for people to stay on Clonazepam solely for panic disorder on a long-term basis without developing a tolerance where I will eventually have to add an SSRI and wean off due to the tolerance issue?  

Thanks in advance

[RCA7591]

There is a discrepancy in your first paragraph. You stated that you had been taking 1.5 mg, b.i.d. for the past eleven years. This would be 3 mg daily. I believe that you meant to write 0.5 mg, t.i.d. (0.5 mg, three times daily), which would be the average dosage for Klonopin. 1.5 mg daily. I would not exceed 2 mg daily unless absolutely necessary, with the upper limit being 3 mg daily. 4 mg is the maximum suggested dosage, but this is excessive.

Have you been experiencing any stress as of late, or anything else that may potentially explain the sudden onset of breakthrough? It would be exceedingly rare for Klonopin to lose its efficacy over the long-term, but it would not be uncommon to require a trivial increase OR decrease of the daily dosage (typically, an additional 0.5 mg) over the long-term. Doubling the dosage is not necessary (or desirable), as dosages in excess of 4 mg ARE associated with the development of tolerance. Larger dosages rarely have a therapeutic effect, but they are typically associated with greater sedation, memory problems, etc. 2-3 mg is the upper limit of normal, and any dosage in excess of this is not likely to produce beneficial results.

If you are concerned about the additional 0.5 mg dose that you've taken for 16 days, merely cut it in half and continue to take it for 10 days. This will eliminate the extra dose without the possibility of withdrawal. If you plan to do this, do it as soon as possible (and under doctor supervision). The extra dose has reached steady-state, but has not yet accumulated.

Post back and tell me exactly how you were taking the Klonopin prior to the increase (ie: the dosage, and how many times per day you took it). I need to know the exact dosage to offer solid suggestions.

To answer your last question - Paxil has no useful indication in the management of panic disorder. Paxil cannot replace Klonopin, as the two drugs target unique neurotransmitters. They are not cross-tolerant. Klonopin is the best long-term viable option currently available for the management of panic disorder. It will not lose its efficacy, and tolerance will not develop if the daily dosage is less than 3 mg daily.

The concomitant use of Klonopin with an SSRI such as Paxil will render the Klonopin less effective in the case of panic disorder.

Ryan

[RCA7591]

Another question:

You stated that you've been taking generic Clonazepam. Has your generic brand been changed recently? Clonazepam is an NTI drug (narrow therapeutic index). Bioavailability has been noted to vary by as much as 30% between the various brands of generic Clonazepam.

Whenever possible, I suggest remaining with one brand, due to this discrepancy in bioavailability. Caraco, Mylan, PurePac, Watson, and Teva are the more common manufacturers.

It should be borne in mind that negative results from switching between one generic to another may not manifest for a period of up to one month. Perhaps this is the culprit in your case? I leave no stone unturned.

Ryan

[Pa1965]

Woops - typo on the first paragraph - sorry.  I was taking 1 mg bid for a total of 2mgs per day for 11 years before the increase in dosage, and am now taking 1.25 mgs bid for a total of 2.5 mgs per day.  My original doctor prescribed it as bid due to it's long half life.

I'm glad to hear dosages under 3 mgs per day (which I've never been at and don't ever want to be at) won't cause tolerance or lose efficacy.  Thanks for clearing that up.  The controversy on this alone has exacerbated my anxiety.

So since I'm taking this medication bid, how would I cut it in half?  Would I reduce both morning and evening pills by .125 mgs (half of .25 mgs) at the same time for 10 days, or reduce only my morning pill by .125 mgs for 10 days, then after that, decrease the night dose by .125 mgs for another 10 days?  I may even need this extra dosage, so not even sure if weaning back is something I should be doing anyway.  And my doctor is of no help since he wants me off the medication completely and on SSRIs.  I can't imagine life without Clonazepam since it's worked so well for me for so many years.  I'm in the process of trying to find a new doctor who isn't opposed to prescribing something for me that has been working.

I've been on a generic brand of Clonazepam all along by the same manufacturer (Pharmascience).  The drugstore (Wal-mart) told me that they could order the brand name from Roche if I wanted it.  What would you suggest?

Thanks for all of your expert advice, Ryan.  I really appreciate your input.
  

[Pa1965]

I forgot to answer your question regarding any increased stressed levels.  Actually, I did experience some stress which caused days of insomnia before the attacks broke through.  So I think between the lack of sleep and stress, it might have brought on the higher anxiety levels and I ended up in a loop where the attacks kept me from sleeping, and the lack of sleep exacerbated anxiety even more to where the two were feeding on each.  

Thanks again for your reply.

[Pa1965]

One more thing you should probably know - I've been on this increased dose of .5 mgs per day for 21 days now.  When I first wrote my posting, it was around 16 days I'd been on it.  I thought I should let you know in case that changes the way I'm to wean back down to my maintenance dose.

Thanks again.

[Pa1965]

Bump

[Pa1965]

Bump