ee clinical pharmacology, clinical trials ). panic disorder (dsm-v) is characterized by recurrent unexpected panic attacks, i.e., 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 tablets 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 tablets for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient (see dosage and administration ).

nce with cognitive and motor performance since clonazepam produces cns depression, patients receiving this drug should be cautioned against engaging in hazardous occupations requiring mental alertness, such as operating machinery or driving a motor vehicle. they should also be warned about the concomitant use of alcohol or other cns-depressant drugs during clonazepam therapy (see precautions: drug interactions and precautions: information for patients ). suicidal behavior and ideation antiepileptic drugs (aeds), including clonazepam, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. patients treated with any aed for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different aeds showed that patients randomized to one of the aeds had approximately twice the risk (adjusted relative risk 1.8, 95% ci:1.2, 2.7) of suicidal thinking or behavior compared to patients randomized to placebo. in these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27,863 aed-treated patients was 0.43% compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behavior for every 530 patients treated. there were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide. the increased risk of suicidal thoughts or behavior with aeds was observed as early as one week after starting drug treatment with aeds and persisted for the duration of treatment assessed. because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed. the risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. the finding of increased risk with aeds of varying mechanisms of action and across a range of indications suggests that the risk applies to all aeds used for any indication. the risk did not vary substantially by age (5 to 100 years) in the clinical trials analyzed. table 1 shows absolute and relative risk by indication for all evaluated aeds. table 1: risk by indication for antiepileptic drugs in the pooled analysis indication placebo patients with events per 1000 patients drug patients with events per 1000 patients relative risk: incidence of events in drug patients/incidence in placebo patients risk difference: additional drug patients with events per 1000 patients epilepsy 1.0 3.4 3.5 2.4 psychiatric 5.7 8.5 1.5 2.9 other 1.0 1.8 1.9 0.9 total 2.4 4.3 1.8 1.9 the relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications. anyone considering prescribing clonazepam or any other aed must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. epilepsy and many other illnesses for which aeds are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated. patients, their caregivers, and families should be informed that aeds increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. behaviors of concern should be reported immediately to healthcare providers. withdrawal symptoms withdrawal symptoms of the barbiturate type have occurred after the discontinuation of benzodiazepines (see drug abuse and dependence ).

s. dosage should be increased by no more than 0.25 to 0.5 mg every third day until a daily maintenance dose of 0.1 to 0.2 mg/kg of body weight has been reached, unless seizures are controlled or side effects preclude further increase. whenever possible, the daily dose should be divided into three equal doses. if doses are not equally divided, the largest dose should be given before retiring. geriatric patients there is no clinical trial experience with clonazepam in seizure disorder patients 65 years of age and older. in general, elderly patients should be started on low doses of clonazepam and observed closely (see precautions, geriatric use ). panic disorder adults the initial dose for adults with panic disorder is 0.25 mg bid. an increase to the target dose for most patients of 1 mg/day may be made after 3 days. the recommended dose of 1 mg/day is based on the results from a fixed dose study in which the optimal effect was seen at 1 mg/day. higher doses of 2, 3 and 4 mg/day in that study were less effective than the 1 mg/day dose and were associated with more adverse effects. nevertheless, it is possible that some individual patients may benefit from doses of up to a maximum dose of 4 mg/day, and in those instances, the dose may be increased in increments of 0.125 to 0.25 mg bid every 3 days until panic disorder is controlled or until side effects make further increases undesired. to reduce the inconvenience of somnolence, administration of one dose at bedtime may be desirable. treatment should be discontinued gradually, with a decrease of 0.125 mg bid every 3 days, until the drug is completely withdrawn. there is no body of evidence available to answer the question of how long the patient treated with clonazepam should remain on it. therefore, the physician who elects to use clonazepam for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient. pediatric patients there is no clinical trial experience with clonazepam in panic disorder patients under 18 years of age. geriatric patients there is no clinical trial experience with clonazepam in panic disorder patients 65 years of age and older. in general, elderly patients should be started on low doses of clonazepam and observed closely (see precautions, geriatric use ).

levations of serum transaminases and alkaline phosphatase musculoskeletal: muscle weakness, pains miscellaneous: dehydration, general deterioration, fever, lymphadenopathy, weight loss or gain neurologic: abnormal eye movements, aphonia, choreiform movements, coma, diplopia, dysarthria, dysdiadochokinesis, “glassy-eyed” appearance, headache, hemiparesis, hypotonia, nystagmus, respiratory depression, slurred speech, tremor, vertigo psychiatric: confusion, depression, amnesia, hysteria, increased libido, insomnia, psychosis (the behavior effects are more likely to occur in patients with a history of psychiatric disturbances). the following paradoxical reactions have been observed: irritability, aggression, agitation, nervousness, hostility, anxiety, sleep disturbances, nightmares, abnormal dreams and hallucinations. respiratory: chest congestion, rhinorrhea, shortness of breath, hypersecretion in upper respiratory passages panic disorder adverse events during exposure to clonazepam were obtained by spontaneous report and recorded by clinical investigators using terminology of their own choosing. consequently, it is not possible to provide a meaningful estimate of the proportion of individuals experiencing adverse events without first grouping similar types of events into a smaller number of standardized event categories. in the tables and tabulations that follow, cigy dictionary terminology has been used to classify reported adverse events, except in certain cases in which redundant terms were collapsed into more meaningful terms, as noted below. the stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse event of the type listed. an event was considered treatment-emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation. adverse findings observed in short-term, placebo-controlled trials adverse events associated with discontinuation of treatment overall, the incidence of discontinuation due to adverse events was 17% in clonazepam compared to 9% for placebo in the combined data of two 6 to 9 week trials. the most common events (≥ 1%) associated with discontinuation and a dropout rate twice or greater for clonazepam than that of placebo included the following: table 2: most common adverse events (≥ 1%) associated with discontinuation of treatment adverse event clonazepam (n = 574) placebo (n = 294) somnolence 7% 1% depression 4% 1% dizziness 1% < 1% nervousness 1% 0% ataxia 1% 0% intellectual ability reduced 1% 0% adverse events occurring at an incidence of 1% or more among clonazepam-treated patients table 3 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred during acute therapy of panic disorder from a pool of two 6 to 9 week trials. events reported in 1% or more of patients treated with clonazepam (doses ranging from 0.5 to 4 mg/day) and for which the incidence was greater than that in placebo-treated patients are included. the prescriber should be aware that the figures in table 3 cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses and investigators. the cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the side effect incidence in the population studied. table 3: treatment-emergent adverse event incidence in 6 to 9 week placebo-controlled clinical trials events reported by at least 1% of patients treated with clonazepam and for which the incidence was greater than that for placebo. clonazepam maximum daily dose adverse event by body system < 1 mg n = 96 % 1 to < 2 mg n = 129 % 2 to < 3 mg n = 113 % ≥ 3 mg n = 235 % all clonazepam groups n = 574 % placebo n = 294 % central & peripheral nervous system somnolence indicates that the p-value for the dose-trend test (cochran-mantel-haenszel) for adverse event incidence was ≤ 0.10. 26 35 50 36 37 10 dizziness 5 5 12 8 8 4 coordination abnormal 1 2 7 9 6 0 ataxia 2 1 8 8 5 0 dysarthria 0 0 4 3 2 0 psychiatric depression 7 6 8 8 7 1 memory disturbance 2 5 2 5 4 2 nervousness 1 4 3 4 3 2 intellectual ability reduced 0 2 4 3 2 0 emotional lability 0 1 2 2 1 1 libido decreased 0 1 3 1 1 0 confusion 0 2 2 1 1 0 respiratory system upper respiratory tract infection 10 10 7 6 8 4 sinusitis 4 2 8 4 4 3 rhinitis 3 2 4 2 2 1 coughing 2 2 4 0 2 0 pharyngitis 1 1 3 2 2 1 bronchitis 1 0 2 2 1 1 gastrointestinal system constipation 0 1 5 3 2 2 appetite decreased 1 1 0 3 1 1 abdominal pain 2 2 2 0 1 1 body as a whole fatigue 9 6 7 7 7 4 allergic reaction 3 1 4 2 2 1 musculoskeletal myalgia 2 1 4 0 1 1 resistance mechanism disorders influenza 3 2 5 5 4 3 urinary system micturition frequency 1 2 2 1 1 0 urinary tract infection 0 0 2 2 1 0 vision disorders blurred vision 1 2 3 0 1 1 reproductive disorders denominators for events in gender-specific systems are: n = 240 (clonazepam), 102 (placebo) for male, and 334 (clonazepam), 192 (placebo) for female. female dysmenorrhea 0 6 5 2 3 2 colpitis 4 0 2 1 1 1 male ejaculation delayed 0 0 2 2 1 0 impotence 3 0 2 1 1 0 commonly observed adverse events table 4: incidence of most commonly observed adverse events treatment-emergent events for which the incidence in the clonazepam patients was ≥ 5% and at least twice that in the placebo patients. in acute therapy in pool of 6 to 9 week trials adverse event clonazepam (n = 574) placebo (n = 294) somnolence 37% 10% depression 7% 1% coordination abnormal 6% 0% ataxia 5% 0% treatment-emergent depressive symptoms in the pool of two short-term placebo-controlled trials, adverse events classified under the preferred term “depression” were reported in 7% of clonazepam-treated patients compared to 1% of placebo-treated patients, without any clear pattern of dose relatedness. in these same trials, adverse events classified under the preferred term “depression” were reported as leading to discontinuation in 4% of clonazepam-treated patients compared to 1% of placebo-treated patients. while these findings are noteworthy, hamilton depression rating scale (ham-d) data collected in these trials revealed a larger decline in ham-d scores in the clonazepam group than the placebo group suggesting that clonazepam-treated patients were not experiencing a worsening or emergence of clinical depression. other adverse events observed during the premarketing evaluation of clonazepam in panic disorder following is a list of modified cigy terms that reflect treatment-emergent adverse events reported by patients treated with clonazepam at multiple doses during clinical trials. all reported events are included except those already listed in table 3 or elsewhere in labeling, those events for which a drug cause was remote, those event terms which were so general as to be uninformative, and events reported only once and which did not have a substantial probability of being acutely life-threatening. it is important to emphasize that, although the events occurred during treatment with clonazepam, they were not necessarily caused by it. events are further categorized by body system and listed in order of decreasing frequency. these adverse events were reported infrequently, which is defined as occurring in 1/100 to 1/1000 patients. body as a whole: weight increase, accident, weight decrease, wound, edema, fever, shivering, abrasions, ankle edema, edema foot, edema periorbital, injury, malaise, pain, cellulitis, inflammation localized cardiovascular disorders: chest pain, hypotension postural central and peripheral nervous system disorders: migraine, paresthesia, drunkenness, feeling of enuresis, paresis, tremor, burning skin, falling, head fullness, hoarseness, hyperactivity, hypoesthesia, tongue thick, twitching gastrointestinal system disorders: abdominal discomfort, gastrointestinal inflammation, stomach upset, toothache, flatulence, pyrosis, saliva increased, tooth disorder, bowel movements frequent, pain pelvic, dyspepsia, hemorrhoids hearing and vestibular disorders: vertigo, otitis, earache, motion sickness heart rate and rhythm disorders: palpitation metabolic and nutritional disorders: thirst, gout musculoskeletal system disorders: back pain, fracture traumatic, sprains and strains, pain leg, pain nape, cramps muscle, cramps leg, pain ankle, pain shoulder, tendinitis, arthralgia, hypertonia, lumbago, pain feet, pain jaw, pain knee, swelling knee platelet, bleeding and clotting disorders: bleeding dermal psychiatric disorders: insomnia, organic disinhibition, anxiety, depersonalization, dreaming excessive, libido loss, appetite increased, libido increased, reactions decreased, aggression, apathy, disturbance in attention, excitement, anger, hunger abnormal, illusion, nightmares, sleep disorder, suicide ideation, yawning reproductive disorders, female: breast pain, menstrual irregularity reproductive disorders, male: ejaculation decreased resistance mechanism disorders: infection mycotic, infection viral, infection streptococcal, herpes simplex infection, infectious mononucleosis, moniliasis respiratory system disorders: sneezing excessive, asthmatic attack, dyspnea, nosebleed, pneumonia, pleurisy skin and appendages disorders: acne flare, alopecia, xeroderma, dermatitis contact, flushing, pruritus, pustular reaction, skin burns, skin disorder special senses other, disorders: taste loss urinary system disorders: dysuria, cystitis, polyuria, urinary incontinence, bladder dysfunction, urinary retention, urinary tract bleeding, urine discoloration vascular (extracardiac) disorders: thrombophlebitis leg vision disorders: eye irritation, visual disturbance, diplopia, eye twitching, styes, visual field defect, xerophthalmia

ation half-life of clonazepam is typically 30 to 40 hours. clonazepam pharmacokinetics are dose-independent throughout the dosing range. there is no evidence that clonazepam induces its own metabolism or that of other drugs in humans. pharmacokinetics in demographic subpopulations and in disease states controlled studies examining the influence of gender and age on clonazepam pharmacokinetics have not been conducted, nor have the effects of renal or liver disease on clonazepam pharmacokinetics been studied. because clonazepam undergoes hepatic metabolism, it is possible that liver disease will impair clonazepam elimination. thus, caution should be exercised when administering clonazepam to these patients (see contraindications ). in children, clearance values of 0.42 ± 0.32 ml/min/kg (ages 2 to 18 years) and 0.88 ± 0.4 ml/min/kg (ages 7 to 12 years) were reported; these values decreased with increasing body weight. ketogenic diet in children does not affect clonazepam concentrations. clinical trials panic disorder the effectiveness of clonazepam in the treatment of panic disorder was demonstrated in two double-blind, placebo-controlled studies of adult outpatients who had a primary diagnosis of panic disorder (dsm-iiir) with or without agoraphobia. in these studies, clonazepam was shown to be significantly more effective than placebo in treating panic disorder on change from baseline in panic attack frequency, the clinician’s global impression severity of illness score and the clinician’s global impression improvement score. study 1 was a 9 week, fixed-dose study involving clonazepam doses of 0.5, 1, 2, 3 or 4 mg/day or placebo. this study was conducted in four phases: a 1 week placebo lead-in, a 3 week upward titration, a 6 week fixed dose, and a 7 week discontinuance phase. a significant difference from placebo was observed consistently only for the 1 mg/day group. the difference between the 1 mg dose group and placebo in reduction from baseline in the number of full panic attacks was approximately 1 panic attack per week. at endpoint, 74% of patients receiving clonazepam 1 mg/day were free of full panic attacks, compared to 56% of placebo-treated patients. study 2 was a 6 week, flexible-dose study involving clonazepam in a dose range of 0.5 to 4 mg/day or placebo. this study was conducted in three phases: a 1 week placebo lead-in, a 6 week optimal-dose, and a 6 week discontinuance phase. the mean clonazepam dose during the optimal dosing period was 2.3 mg/day. the difference between clonazepam and placebo in reduction from baseline in the number of full panic attacks was approximately 1 panic attack per week. at endpoint, 62% of patients receiving clonazepam were free of full panic attacks, compared to 37% of placebo-treated patients. subgroup analyses did not indicate that there were any differences in treatment outcomes as a function of race or gender.

ies examining the influence of gender and age on clonazepam pharmacokinetics have not been conducted, nor have the effects of renal or liver disease on clonazepam pharmacokinetics been studied. because clonazepam undergoes hepatic metabolism, it is possible that liver disease will impair clonazepam elimination. thus, caution should be exercised when administering clonazepam to these patients (see contraindications ). in children, clearance values of 0.42 ± 0.32 ml/min/kg (ages 2 to 18 years) and 0.88 ± 0.4 ml/min/kg (ages 7 to 12 years) were reported; these values decreased with increasing body weight. ketogenic diet in children does not affect clonazepam concentrations.

number of full panic attacks was approximately 1 panic attack per week. at endpoint, 74% of patients receiving clonazepam 1 mg/day were free of full panic attacks, compared to 56% of placebo-treated patients. study 2 was a 6 week, flexible-dose study involving clonazepam in a dose range of 0.5 to 4 mg/day or placebo. this study was conducted in three phases: a 1 week placebo lead-in, a 6 week optimal-dose, and a 6 week discontinuance phase. the mean clonazepam dose during the optimal dosing period was 2.3 mg/day. the difference between clonazepam and placebo in reduction from baseline in the number of full panic attacks was approximately 1 panic attack per week. at endpoint, 62% of patients receiving clonazepam were free of full panic attacks, compared to 37% of placebo-treated patients. subgroup analyses did not indicate that there were any differences in treatment outcomes as a function of race or gender.

ed room temperature]. manufactured in israel by: teva pharmaceutical ind. ltd. jerusalem, 9777402, israel manufactured for: teva pharmaceuticals usa, inc. north wales, pa 19454 rev. v 10/2017