Branded clonazepam (Klonopin) is supplied as tablets with a K-shaped perforation containing 0.5 mg of clonazepam and unscored tablets with a K-shaped perforation containing 1 mg or 2 mg of clonazepam. These tablets also contain the following inactive ingredients: lactose, magnesium stearate, microcrystalline cellulose and corn starch, with the following colorants: 0.5 mg—FD&C Yellow No. 6 Lake; 1 mg—FD&C Blue No. 1 Lake and FD&C Blue No. 2 Lake.
Clonazepam is also supplied as scored orally disintegrating tablets containing 0.125 mg, 0.25 mg, 0.5 mg, 1 mg or 2 mg clonazepam. These tablets are usually dissolved sub-lingually. These contain the following inactive ingredients: gelatin, mannitol, methylparaben sodium, propylparaben sodium and xanthan gum.
Generic clonazepam are supplied in the form of 0.5 mg, 1 mg or 2 mg scored orally disintegrating tablets.
Clonazepam is also supplied as Rivotril in 1mg/ml sterile solution as listed in the attached information from electronic Medicines Compendium.
[top]Ways of Administration
Tablets taken orally are swallowed according to the desired dosage. Scored tablets may be broken to adjust dosage.
[top]Sub-lingual
The orally disintegrating tablets are administered sublingually where some of the dose is absorbed through the mucous membrane, but more so the tablet is dissolved in saliva so it can be administered either with or without water.
[top]Insufflation
Tablets may be ground into a powder and insufflated, but this is not really more effective than sublingual absorption. Additionally, unless it is extracted the binders and fillers will be insufflated as well.
Rivotril sterile concentrate is for intravenous administration. For the treatment of accute seizures (status epilepticus) with the dose and rate of administration governed by the response of the patient.
Adults
1mg (one ampoule of active substance mixed with one ampoule of solvent for parenteral use) by slow
intravenous injection.
Elderly
Special care and monitoring must be taken with use of clonazepam in the elderly because they tend to metabolize drugs more slowly. Clonazepam has a half-life longer than a day. With daily or more frequent dosing clonazapam levels can accumulate and rise to dangerous levels possibly causing respiratory depression which is potentially fatal.
Children
0.5mg (equivalent to half an ampoule of active substance mixed with half an ampoule of solvent for parenteral use) by slow intravenous injection. Clonazepam is indicated in children
only for the treatment of seizures.
Special dosage instructions
Rivotril can be administered with one or several other antiepileptic agents, in which case the dosage of each
drug must be adjusted to achieve optimum effect.
As with all antiepileptic agents, treatment with Rivotril must not be stopped abruptly, but must be reduced in a stepwise fashion (see section 4.8 Undesirable effects).
Mode of administration
Rivotril must be diluted prior to administration in order to avoid irritation of the veins, see section 6.6 Instructions for use/handling.
Intravenous injection of Rivotril should be into a large vein of the antecubital fossa. The injection should be given slowly - in adults, the rate of injection must not exceed 0.25mg – 0.5mg (0.5 – 1.0ml of the prepared solution) per minute – and should be administered with continuous monitoring of EEG, respiration and blood pressure. This will greatly diminish the rare possibility of hypotension or apnoea occurring. Nevertheless, facilities for resuscitation should always be available. A total dose of 20mg should not be exceeded.
Rivotril sterile concentrate may be diluted when given in intravenous infusions of saline or glucose, such as are customary in the treatment of status epilepticus.
[top]Effects of Clonazepam
The precise mechanism by which clonazepam exerts its antiseizure and antipanic effects is unknown, although it is believed to be related to its ability to enhance the activity of gamma aminobutyric acid (GABA), the major inhibitory
neurotransmitter in the central nervous system. Convulsions produced in rodents by pentylenetetrazol or, to a lesser extent, electrical stimulation are antagonized, as are convulsions produced by photic stimulation in susceptible baboons. A taming effect in aggressive primates, muscle weakness and hypnosis are also produced. In humans, clonazepam is capable of suppressing the spike and wave discharge in absence seizures (petit mal) and decreasing the frequency, amplitude, duration and spread of discharge in minor motor seizures.
Because benzodiazepines have the potential to impair judgment, thinking or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that clonazepam therapy does not affect them adversely.
[top]Combinations with Clonazepam
Clonazepam can interact dangerously with other central nervous system
depressants, increasing the likelihood of greater respiratory depression and in other effects such as lack of coordination, dizziness, low blood pressure, unconsciousness and even coma. These depressants include
alcohol, other benzodiazepines, barbiturates, antipsychotics, sedative antihistamines, anticonvulsants, delirant and dissociative drugs, muscle relaxants,
opioids/opiates, sedative/hypnotics, anxiolytics, narcotic analgesics, anesthetics, MAO inhibitors, and other
antidepressants.
Alcohol use with clonazepam is not recommended because the two have a tendency to potentiate CNS depressant effects which can include somnolence, confusion, coma and diminished reflexes and even death.
[top]Antidepressants
With some antidepressants clonazepam is indicated to reduce the potential risk of seizure.
Clonazepam has been known to moderate the anxiety associated with
cocaine use.
Benzodiazepines such as clonazepam are indicated for acute cocaine ingestion in order to moderate the effects, though sometimes additional treatments such as nitroglycerine therapy are require in extreme cases.(need reference)
Some users have reported that regular daily use of clonazepam can significantly reduce the effects of
LSD.
Anecdotally, clonazepam is indicated for acute LSD ingestion in order to moderate the effects.(need reference)
[top]Other Drugs
Clonazepam does not appear to alter the pharmacokinetics of phenytoin, carbamazepine or phenobarbital. The effect of clonazepam on the metabolism of other drugs has not been investigated.
[top]Different Uses for Clonazepam
[top]Seizure Disorders
Clonazepam is useful alone or as an adjunct in the treatment of the Lennox-Gastaut syndrome (petit mal variant), akinetic and myoclonic seizures. In patients with absence seizures (petit mal) who have failed to respond to succinimides, clonazepam may be useful.
In some studies, up to 30% of patients have shown a loss of anticonvulsant activity, often within 3 months of administration. In some cases, dosage adjustment may reestablish efficacy.
[top]Panic Disorder
Clonazepam is indicated for the treatment of panic disorder, with or without agoraphobia, as defined in DSM-IV. Panic disorder is characterized by the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks, and/or a significant change in behavior related to the attacks.
The efficacy of clonazepam was established in two 6- to 9-week trials in panic disorder patients whose diagnoses corresponded to the DSM-IIIR category of panic disorder.
Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, ie, a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (1) palpitations, pounding heart or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes.
The effectiveness of clonazepam in long-term use, that is, for more than 9 weeks, has not been systematically studied in controlled clinical trials. The physician who elects to use clonazepam for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient.
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