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Litespen.orgMaximum clonazepam dosage

Benzodiazepines Johns Hopkins Psychiatry Guide


8.21.2018 | Aidan Jerome

Increased levels of diazepam.

3 mg (60): $319.35 ER Tablets: Brand :

Alprazolam: Changes in appetite (decrease or increase), weight gain, reduced mucosal production leading to xerostomia and constipation, confusion, sedation, cognitive impairment, memory impairment, irritability Chlordiazepoxide: Edema, constipation, nausea, confusion, sedation, cognitive impairment, memory impairment, irritability Clonazepam: Depression, ataxia, dizziness, confusion, sedation, cognitive impairment, memory impairment, irritability, upper respiratory infection, respiratory depression Diazepam: Hypotension, ataxia, dizziness, confusion, sedation, cognitive impairment Lorazepam: Depression, ataxia, dizziness, confusion, sedation, cognitive impairment Oxazepam: Dizziness, headache, sedation.

Increased levels of diazepam.

0.5 to 1 mg three times a day-four times a day Tablet: Brand :

Maximum clonazepam dosage
Benzodiazepines Johns Hopkins Psychiatry Guide

Increased levels of alprazolam Avoid use.

Reduce lorazepam starting dose by 50%; adjust dose further as needed General Precautions: CNS Depressants.

Monitor for sedative effects, and adjust dose of one or both as needed.

0.5 mg (100): $898.14.

2 mg (100): $128.45.

Adjust dose of diazepam as needed, or change to a benzodiazepine eliminated by glucuronidation.

Increased levels of lorazepam.

Increased levels of diazepam.

Adjust dose of benzodiazepine as needed.

Adjust dose of diazepam as needed.

Increased sedative/CNS depressant effects.

Alprazolam – carbamazepine (Tegretol).

1 mg (100): $410.72.

Alprazolam – delavirdine (Rescriptor) +

Reduce hydrocodone dose ~25% Methadone.

Alprazolam – fluvoxamine (Luvox).

1 mg (60): $168.46.

0.5 to 1 mg three times a day Maximum 20 mg/day Tablets: Brand :

Increased sedative/CNS depressant effects.

Liquid (1 mg/mL, 30-mL bottle): Generic only: $81.05 Librium Chlordiazepoxide Multiple generic manufacturers PO Capsule.

Elderly patients often require lower benzodiazepine doses due to slower metabolism of the drugs.

0.25 mg (60): $77.93.

10 to 30 mg three times a day-four times a day Maximum 120 mg/day.

5 mg (100): $508.68.

Avoid use of parenteral benzodiazepines and IM olanzapine.

If necessary, adjust dose of alprazolam as needed.

5 mg (100): $16.35.

Increased levels of alprazolam Avoid use.

Diazepam - itraconazole (Sporanox).

1 mg (100): $280.03.

Adjust dose of alprazolam as needed.

Monitor levels of digoxin, and reduce dose as needed.

0.5 mg (60): $135.40.

30 mg (100): $210.39.

2 mg (60): $123.19 Valium Diazepam Roche Multiple generic manufacturers PO Tablet Liquid.

Chlordiazepoxide, clonazepam – ketoconazole.

Increased levels of diazepam.

5 to 25 mg three times a day-four times a day Maximum 40 mg/day Tablet: Brand :

If necessary, adjust dose of alprazolam as needed.

10 mg (100): $39.78.

Adjust dose of diazepam as needed, or change to a benzodiazepine eliminated by glucuronidation.

Eur J Clin Pharmacol 9:155, 1975 Boudinot FD et al: Protein binding of oxazepam and its glucuronide conjugates to human albumin. Nemeroff CB: Anxiolytics: past, present, and future agents. J Clin Psychiatry 65 Suppl 5:29, 2004. Psychother Psychosom 82:355, 2013 Davidson JR: Use of benzodiazepines in social anxiety disorder, generalized anxiety disorder, and posttraumatic stress disorder. J Clin Psychiatry 64 Suppl 3:3, 2003 Chouinard G: Issues in the clinical use of benzodiazepines: potency, withdrawal, and rebound. Clin Pharmacokinet 24:453, 1993 Greenblatt DJ et al: Clinical pharmacokinetics of chlordiazepoxide. Clin Pharmacokinet 3:381, 1978 Sep-Oct Berlin A, Dahlström H: Pharmacokinetics of the anticonvulsant drug clonazepam evaluated from single oral and intravenous doses and by repeated oral administration. Gen Hosp Psychiatry 35:3, 2013 Jan-Feb Greenblatt DJ, Wright CE: Clinical pharmacokinetics of alprazolam. Therapeutic implications. Eur J Clin Pharmacol 35:385, 1988 Offidani E et al: Efficacy and tolerability of benzodiazepines versus antidepressants in anxiety disorders: a systematic review and meta-analysis. J Clin Psychiatry 65 Suppl 5:7, 2004 Bellantuono C et al: Benzodiazepine exposure in pregnancy and risk of major malformations: a critical overview. Biochem Pharmacol 34:2115, 1985 Sonne J et al: Bioavailability and pharmacokinetics of oxazepam.

3 mg (60): $335.36 ODT (generic only):

Adjust dose of alprazolam as needed.

0.5 mg (60): $299.93.

Reduce lorazepam starting dose by 50%; adjust dose further as needed.

Monitor phenytoin levels, and adjust dose as needed Lorazepam - probenecid.

Alprazolam – indinavir (Crixivan) +

Reduced levels of phenytoin.

Alprazolam – aprevir (Incivek).

5 mg (100): $35.25.

Benzodiazepines are often used to “bridge” patients who are starting an "antidepressant" for anxiety, since the therapeutic effects may be delayed, and patients may experience stimulating side effects initially. The risk of dependence is increased with the agents that are rapidly absorbed and with shorter half-lives, i.e., alprazolam and diazepam. Although beneficial for the acute relief of anxiety, long-term use of benzodiazepines is not recommended due to the risk of dependence. One may preferably choose lorazepam or oxazepam: both are metabolized through conjugation and do not produce active metabolites (fewer CYP 450 drug interactions). However, benzodiazepines may worsen symptoms in patients with comorbid depression or PTSD. Benzodiazepines may be beneficial for long-term use in refractory cases. Benzodiazepines may be more effective than antidepressants for social anxiety disorder. Although tolerance to the anxiolytic effects is uncommon, avoid use in patients with a history of substance use disorder.

10 mg (100): $115.19.

2 mg (100): $118.45 ODT: Generic :

Alprazolam – itraconazole (Sporanox) +

Alprazolam – cobicistat (Stribild).

Adjust dose of clonazepam as needed.

Alprazolam: Decreased libido Chlordiazepoxide: Irregular menses, decreased libido Clonazepam: Suicidal ideation Diazepam: Muscle weakness, respiratory depression; rash and diarrhea can occur with rectal gel use Lorazepam: Delirium (especially in elderly patients), weakness.

Alprazolam: 0.8-1.3 L/kg Chlordiazepoxide: 0.25-0.5 L/kg Clonazepam: 1.5-4.4 L/kg Diazepam: 1 L/kg Lorazepam: 1.3 L/kg Oxazepam: 0.59 L/kg.

Adjust dose of benzodiazepine as needed.

5 to 25 mg three times a day-four times a day Maximum 100 mg/day.

0.5 mg (100): $271.93.

1 mg (60): $88.91.

Monitor for sedative effects, and adjust dose of one or both as needed Clozapine (Clozari).

2 mg (100): $327.06.

If used, choose an agent with a shorter half-life. Long-term effects from exposure are unknown, but all benzodiazepines can cross into the breast milk; thus, the baby may experience side effects, including respiratory depression, sedation, difficulty breastfeeding and hypotonia - also known as “floppy baby syndrome.” In general, benzodiazepines may have a longer half-life in babies (who have not developed the mechanisms for metabolism).

Increased levels of alprazolam Avoid use.

Diazepam - fluvoxamine (Luvox).

Generalized anxiety disorder (GAD) Social phobia Panic disorder Insomnia Status epilepticus/seizures Premedication for anesthetic procedures.

Reduce starting dose of alprazolam by 50%; adjust dose further as needed.

0.25 mg (100): $218.26.

Increased sedative/CNS depressant effects.

10 mg (100): $31.25.

3 mg (60): $742.93 Generic :

0.25 mg to 1 mg three times a day Maximum 4 mg/day Tablets: Brand :

Monitor for sedative effects, and adjust dose of one or both as needed Tapentadol (Nucynta).

Start tapentadol at 1/3 to 1/2 the usual starting dose Zolpidem (Ambien).

2 mg (100): $10.45.

2 mg (100): $1912.10 Generic :

ER = extended release.

Increased sedative/CNS depressant effects.

Increased sedative/CNS depressant effects.

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Increased levels of benzodiazepine.

1 mg (100): $1199.78.

Liquid (5 mg/5 mL, 500-mL bottle): Generic only: $67.83 Ativan Lorazepam Multiple generic manufacturers PO Tablet Liquid.

Clonazepam – carbamazepine (Tegretol).

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1 mg (100): $85.55.

Alprazolam: 12-15 hours Chlordiazepoxide: 24-48 hours Clonazepam: 18-50 hours Diazepam: 20-80 hours Lorazepam: 10-20 hours Oxazepam: 5-11 hours.

Lorazepam – valproate (Depakote).

Alprazolam, clonazepam, diazepam – ritonavir (Norvir).

0.25 mg (100): $241.39.

2 mg (60): $212.90.

Increased sedative/CNS depressant effects.

Adjust dose of alprazolam as needed.

Increased levels of benzodiazepine.

Alprazolam, diazepam – saquinavir (Invirase).

Reduced levels of clonazepam.

Monitor for increased sedative/CNS depressant effects Hydrocodone (Lortab).

Alprazolam (Xanax XR; Xanax) 0.5 Chlordiazepoxide (Librium) 10 Clonazepam (Klonopin) 0.25-0.5 Diazepam (Diastat, Valium) 5 Lorazepam (Ativan) 1 Oxazepam (Serax) 15-30.

1 mg (100): $88.25.

0.5 mg (100): $245.48.

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Alprazolam – ketoconazole +

Alprazolam: No dose adjustment is needed; increase as needed/tolerated Chlordiazepoxide: Patients with renal impairment (CrCl less than 10 mL/min) should have their doses decreased by 50% Clonazepam: No dose adjustment is needed; increase as needed/tolerated Diazepam: No dose adjustment is needed; increase as needed/tolerated Lorazepam: No dose adjustment is needed for mild-to-moderate renal impairment; not recommended for patients with renal failure Oxazepam: No dose adjustment is needed; increase as needed/tolerated.

15 mg (100): $145.45.

Reduced levels of alprazolam.

*Prices represent cost per unit specified, and are representative of "Average Wholesale Price" (AWP).

Adjust dose of alprazolam as needed.

Diazepam – disulfiram (Antabuse).

Increased levels of alprazolam.

0.25 mg (100): $69.50.

If necessary, adjust dose of alprazolam as needed.

0.5 mg (100): $300.72.

Increased levels of alprazolam.

2 mg (60): $495.34.

Diazepam – etravirine (Inence).

10 mg (100): $856.28 Generic :

0.125 mg (60): $77.93.

Increased levels of digoxin.

1 mg (60): $160.40.

Alprazolam: 80% Chlordiazepoxide: 96% Clonazepam: 85% Diazepam: 95-98% Lorazepam: 85-91% Oxazepam: 94-97%

0.5 mg (100): $74.95.

This can be increased to 10 mg two to three times a day Clonazepam: Safety has not been established in children Diazepam: Start at 1 mg two to four times a day, and increase gradually as needed/tolerated Lorazepam: Safety has not been established in children Oxazepam: Safety has not been established for children under 6 years of age. Alprazolam: Safety has not been established in children Chlordiazepoxide: Not recommended for children younger than 6 years of age. No guideline has been established for children between 6 and 12 years of age. For children over 12 years of age, use 10-15 mg three to four times a day. For children older than 6 years of age, use 5 mg two to four times a day.

2 mg (100): $388.01 Generic :

Diazepam, lorazepam – olanzapine (Zyprexa).

2 mg (100): $682.27 Generic :

Diazepam – phenyton (Dilantin), fosphenytoin (Cerebyx).

Alprazolam: No dose adjustment is needed; increase as needed/tolerated Chlordiazepoxide: The maximum dose is 20 mg total/day Clonazepam: No dose adjustment is needed; increase as needed/tolerated Diazepam: Reduce the usual dose by 50% Lorazepam: No dose adjustment is needed for mild-to-moderate liver impairment; not recommended for patients with hepatic failure Oxazepam: No dose adjustment is needed; increase as needed/tolerated.

Increased sedative/CNS depressant effects.

Alprazolam: Stevens-Johnson Syndrome, liver failure Chlordiazepoxide: Agranulocytosis, liver failure Diazepam: Neutropenia Lorazepam: Acidosis.

1 mg (60): $373.20.

When possible, avoid use during the first trimester Minimize use; i.e., reserve for PRN use if possible Weigh the benefit vs. With the exception of paroxetine (category D), all the antidepressants are in category C Avoid use near the time of delivery, as the baby may experience withdrawal symptoms. the risk of continued therapy; if necessary, consider an agent with a short half-life, and use sparingly and intermittently Consider initiating and/or maintaining patients on an antidepressant agent. Benzodiazepines are category D drugs, primarily due to concerns with cleft lip/palate and urogenital and neurological malformations; however, recent literature does not show an increased risk of these.

1 mg (100): $362.81.

25 mg (100): $42.84 Klonopin Clonazepam Roche Multiple generic manufacturers PO Tablet ODT.

ODT = orally disintegrating tablets.

Liquid (2 mg/1 mL, 30-mL bottle): Generic only: $39.60 Serax Oxazepam Multiple generic manufacturers PO Capsule.

Increased levels of alprazolam.

Adjust dose of benzodiazepine as needed.

Benzodiazepines act through the gamma-aminobutyric acid (GABA) A receptor, which regulates chloride entry into neurons, resulting in neuronal hyperpolarization. brand name preparation manufacturer route form dosage cost* Xanax Alprazolam Pfizer Multiple generic manufacturers PO Tablet ER tablet ODT Liquid.

Adjust dose of diazepam as needed.

Increased levels of benzodiazepine.

Agitation Alcohol withdrawal symptoms Muscle spasms Sedation Restless legs syndrome Sleepwalking disorder.

Increased risk of cardiorespiratory depression.

Alprazolam : Well-absorbed orally; bioavailability 90%; time to peak concentration 1-2 hours (intermediate) Chlordiazepoxide : Well-absorbed orally; time to peak concentration several hours (intermediate) Clonazepam : Well-absorbed orally; bioavailability 90%; time to peak concentration 1-4 hours (intermediate) Diazepam: Well-absorbed orally; bioavailability 90%; time to peak concentration 0.5-6 hours (rapid) Lorazepam: Well-absorbed orally; bioavailability 90%; time to peak concentration 1-2 hours (intermediate) Oxazepam : Well-absorbed orally; bioavailability 93%; Time to peak concentration 3 hours (intermediate – slow).

2 mg (60): $223.58.

Most benzodiazepines can cause these side effects due to their inhibitory effects on brain neurotransmission: Anterograde amnesia Confusion Dizziness Depression Sedation Withdrawal symptoms from benzodiazepines (seizures, hallucinations, agitation, tremors) are most common when using benzodiazepines with shorter half-lives.

Alprazolam: Metabolized by the liver (CYP3A4). Excreted primary by kidneys and some via feces Oxazepam: Metabolized by the liver and excreted primary by kidneys. Excreted primary by kidneys and some via feces Chlordiazepoxide: Metabolized by the liver and excreted primary by kidneys Clonazepam: Metabolized by the liver (CYP3A4: oxidation and reduction) and excreted primary by kidneys Diazepam: Metabolized by the liver (CYP2C19 and CYP3A4: glucuronidation, methylation, oxidation, and hydroxylation) and excreted primary by kidneys Lorazepam: Metabolized by the liver (glucuronidation).

Alprazolam – boceprevir (Victrelis).

Increased levels of alprazolam.

Alprazolam, diazepam – Fosamprenavir (Lexiva).

0.5 mg (60): $128.95.

Alprazolam – clarithromycin (Biaxin).

Oral dose equivalences of benzodiazepines : Agent Relative Potency (mg). Although similar in many ways, the choice of an agent is often based on its pharmacokinetic properties, especially onset of action, half-life, and metabolic pathway. The dosage of a benzodiazepine will vary depending on the patient and his or her history of sedative use.

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Decrease dose of benzodiazepine.

Increased levels of alprazolam Avoid use.

If necessary, adjust dose of alprazolam as needed.

Increased levels of alprazolam.

0.5 mg (60): $77.80.

0.5 mg (100): $67.75.

Johns Hopkins Psychiatry Guide Anxiolytics.

Adjust dose of alprazolam as needed.

Benzodiazepine and alcohol can have a synergistic interaction, leading to CNS depression and death. Please refer to standard drug information resources to check for specific interactions. Drug-to-Drug Interactions Drug Effect of Interaction Recommendations/Comments. + = Contraindication This list is not all-inclusive.

Increased levels of lorazepam.

Monitor for sedative effects, and adjust dose of one or both as needed Sodium oxybate (Xyrem).

Adjust dose of benzodiazepine as needed.

Increased levels of benzodiazepine.

Alprazolam, diazepam – digoxin (Lanoxin).

2 mg (100): $616.91.

Chlordiazepoxide: Dose adjustment may be needed in children with renal impairment. Diazepam: No dose adjustment needed Oxazepam: No dose adjustment needed.

Maximum clonazepam dosage