Klonopin Dosage

[Pa1965]

Dr. Gould,

I've been on Clonazepam for 11 years for extreme panic disorder at a steady dose.  As I stated in an earlier post, I was taking 1 mgs b.i.d. but had recently had to increase the dose to 1.25 mgs b.i.d.  Can you tell me if this is considered a high dosage to be on?  I'm concerned as I don't want to get to a point where the drug is no longer effective.  I heard that at dosages 3 mgs per day and over, it loses it's efficacy - not sure the truth behind that, but anything below this doesn't keep the attacks away, and I'm unable to tolerate SSRIs.

Thanks again for your assistance.

[Roger Gould, M.D.]

No, that is not considered to be too high a dose.

[Exbenzo]

Eventually any dose of klonopin will be inadequate. You will need escalating doses to maintain the same effect. This can happen in a few weeks or in 15 years.

Do you want to increase the dose over years or get off of this drug now? Of you chose now, look for expert help. You may be fine, but you may be dependent enough to have a seizure. You can do this with care or risk a lot of pain.

This is a sneaky drug more subtle than other benzodiazepines. Take Care.

[RCA7591]

Eventually any dose of klonopin will be inadequate. You will need escalating doses to maintain the same effect. This can happen in a few weeks or in 15 years.

^quote

Not even remotely correct, fortunately.

Klonopin was designed in 1976 by Roche pharmaceuticals as an anticonvulsant -  for the treatment of petit-mal and other distinct forms of epilepsy. At the time, it was indicated in monotherapy, or as an ajunct to other anticonvulsants for the treatment of epilepsy. The average daily dosages were often high, in the range of 8-10 mg, with a recommended maximum daily dosage of 20 mg. When used as an adjunt or complement to other anticonvulsants, the average dosage was 1.5 mg daily - in three divided doses.

Larger dosages of Klonopin (greater than 4 mg daily) pose a problem, particularly in the treatment of epilepsy. The risk of loss of efficacy is roughly 30% when the dosage exceeds 4 mg. This risk has nothing to do with the drug being a Benzodiazepine, and the anticonvulsant effect is not obtained from the binding of the drug to Benzodiazepine receptor sites, but rather to voltage dependent sodium channels.

In 1998, Klonopin was approved for the treatment of panic disorder. In addition to possessing potent anticonvulsant properties, Klonopin was also found to possess powerful anxiolytic and anti-panic properties. Fortunately, these two attributes are obtainable with far lower daily dosages compared to those used in the treatment of epilepsy (4 mg or less daily for panic disorder). Used in dosages under 4 mg daily, loss of efficacy - particularly in panic disorder, would be extremely uncommon. The method of action differs from that of epilespy, in that the therapeutic benefit is obtained from the binding to Benzodiazepine (GABA) receptor sites, and not voltage dependent sodium channels.

Unlike Ativan, Serax, or Xanax, which are short-acting agents, Klonopin carries an intermediate half-life of 18-50 hours (depending on the individual and their particular metabolism). This prolonged half-life allows for the drug to accumulate to steady-state, where as Ativan, Serax, and Xanax do not. The retainment of a steady-state plasma level not only reduces "interdose phenomena", but greatly reduces the risk of *tolerance*. Thus, Klonopin is approved for the long-term management of panic disorder, while shorter-acting agents such as Ativan, Serax, and Xanax are indicated for p.r.n. or short-term use only. The latter three are associated with rapid tolerance when used over a prolonged period of time. This does not hold true for Klonopin. Klonopin maintains its efficacy through the retainment of steady-state and accumulation.

The three other Benzodiazepines that are indicated for the management of anxiety disorders include Librium, Tranxene, and Valium. Unfortunately, these are not specific for "panic", where as Klonopin has a high affinity towards panic. Furthermore, these three agents tend to accumulate excessively - particularly in the elderly. It is not uncommon for Librium or Valium to accumulate to 5-10 times that of the steady-state level. In comparison, Klonopin accumulates between 1.5 - 3 times that of the steady-state level (and as such, is associated with fewer untoward effects, particularly somnolence).

Of the modern pharmacological treatment options for panic disorder, Klonopin yields the greatest efficacy with relatively few untoward side effects. The SSRI/SNRI class of drugs are largely ineffective, unless some component of depression coexists with the panic disorder. Modern antidepressants almost always tend to amplify the autonomic/sympathetic sensations associated with panic disorder (ie: hyperventilation, tachycardia), as these agents are inherently stimulating.

Ryan

[Pa1965]

Thank you, Ryan!!!

[Sozo]

Thank you, Ryan!

[Sozo]

Good luck and keep me posted on your progress.

[creston1966]

Stop with all the pseudo expertise (ie cut and pasting from the internet).  There is the official answer that most dr's give and their is the reality A LOT of people have experienced with Klonopin.  It can become very habit forming for people (i know from personal experience).  Oh, and look at many, many posts from sites like this.

Klonopin can be very effective short term for anxiety.  What has to be weighed is short term benefit vs long term benefit.  And are you willing to go through some level of discomfort when you decide to stop the drug.  

I'm so glad you are here Ryan to give everyone your 'expert" input.  At least the good Dr here actually (as far as we know) a Dr.  Idiots.

[RCA7591]

Stop with all the pseudo expertise (ie cut and pasting from the internet).

^quote

Every comment that I have written on MedHelp over the past year is from my own objective research. None of the information that I provide comes from the Internet (which is filled with misinformation). Please provide a specific link outlining where I copied and pasted anything in my above comment.

Every pharmacological treatment modaility has a trade-off, and Klonopin's trade-off is a limited physical dependency. This is of no consequence in the long-term management of panic disorder, and it can be managed effectively when discontinued properly. MANY pharmaceuticals carry the same trade-off, including alpha/beta blockers used to treat hypertensive states and irregular heart rhythms, anticonvulsants, etc. Dependency is not limited to the Benzodiazepines.

Furthermore, when used as indicated, Klonopin is NOT habit-forming or addictive. Such terms imply abuse, and abuse is exceedingly rare when the drug is used for a legitimate purpose. Addiction and dependency are two distinct entities. Folks with panic disorder are not prone to addiction, and generally speaking, are "med-phobic". It would not be uncommon for such folks to take less than the recommended dosage. Recall the original posters concerns over the dosage to back this statement.

There is no credible objective evidence that supports the notion that the short-term use of Klonopin (less than four months), results in a reduced risk of withdrawal phenomena when compared to long-term use of the drug (greater than 4 months).

Frankly, the horror stories generated on the Internet could be attributed to many things: (1) Improper dosing, (2) Improper discontinuation, and (3) Reemergence of the underlying disorder which has been falsely mistaken as a form of withdrawal phenomena.
There is almost certainly a strong component of hysteria involved with such stories. Many folks with anxiety/panic disorder are suggestible. Reading online horror stories only serves to fuel their suggestibility, and leads to the propagation of hysteria. If you suggest to others that Klonopin discontinuation results in severe withdrawal phenomena, they are inherently inclined to believe it, and as such, are at an increased risk of developing perceived, subjective untoward effects (which are largely psychogenic in origin).

Thus, it would be wise to follow the recommendations set forth by a  doctor, and to refrain from reading horror stories on the Internet.

Ryan