Rivotril (Clonazepam)
Also sold as: Rivotril, Lonazep, Clonapax, Clonotril, Petril
Pregnancy
Cat D
Lactation
Avoid
Schedule
H
Forms
Tablet 0.25mg, 0.5mg, 1mg, 2mg +2
Indications
- Epilepsy — absence, myoclonic, akinetic seizures
- Lennox-Gastaut syndrome
- Anxiety disorders — generalised anxiety, panic disorder
- Restless legs syndrome (off-label)
- Acute mania adjunct (short-term)
- Neonatal seizures (IV)
Adult Dosing
Epilepsy
Start 0.5 mg PO TDS; increase by 0.5 mg every 3 days to max 20 mg/day
Most patients controlled at 4-8 mg/day. Tolerance develops (most limiting factor).
Panic disorder
0.25-0.5 mg PO BD; max 4 mg/day
Anxiety
0.5-2 mg PO BD-TDS — short-term only (≤4 weeks)
Pediatric Dosing
Use oral drops for precise dosing in infants and young children.
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| Any | No formal adjustment; use lower doses and monitor CNS effects in CKD |
Hepatic Adjustment
Reduce dose significantly in hepatic impairment — extensively hepatically metabolised (CYP3A4). Avoid in severe hepatic impairment.
Pregnancy & Lactation
Pregnancy: Category D
AVOID — risk of cleft palate (especially 1st trimester). Neonatal withdrawal syndrome (floppy infant, respiratory depression). If essential for seizures, use lowest effective dose. Taper before delivery if possible.
Lactation: Avoid
Excreted in breast milk; neonatal sedation, poor feeding reported. Generally avoid; if used, monitor infant closely.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| CNS depressants (opioids, alcohol, other benzodiazepines, antipsychotics) | Additive CNS and respiratory depression — potentially fatal with opioids | Major |
| CYP3A4 inhibitors (itraconazole, clarithromycin, ritonavir) | Increase clonazepam levels — enhanced sedation/toxicity | Major |
| CYP3A4 inducers (rifampicin, carbamazepine, phenytoin) | Reduce clonazepam levels — loss of seizure control | Major |
| Valproate | May precipitate absence status epilepticus in some patients | Moderate |
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Side Effects
Common
- Sedation / drowsiness (most common)
- Ataxia
- Cognitive impairment (long-term)
- Tolerance and dependence (with chronic use)
- Hypersalivation (in children)
- Disinhibition / paradoxical excitement
Serious / Discontinue If
- Respiratory depression (IV or high dose, especially with opioids)
- Severe physical dependence — withdrawal seizures if stopped abruptly
- Paradoxical agitation, aggression (more in children, elderly)
- Suicidal ideation (all anticonvulsants — class warning)
Contraindications
- Respiratory depression / COPD (severe)
- Sleep apnoea
- Myasthenia gravis
- Severe hepatic impairment
- Acute narrow-angle glaucoma
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Rivotril 0.5mg | Roche | 30 tab ₹85 |
| Lonazep 0.5mg | Sun Pharma | 30 tab ₹58 |
| Clonotril 0.5mg | Torrent | 30 tab ₹52 |
| Petril 0.5mg | Micro Labs | 30 tab ₹45 |
Monitoring Required
- Level of sedation and ataxia (dose-titration)
- Signs of tolerance (increasing seizure frequency despite stable dose)
- Respiratory rate (IV or high doses)
- Hepatic function (hepatic metabolism)
- Dependence assessment — avoid abrupt withdrawal
Patient Counseling Points
- DO NOT stop suddenly — risk of severe withdrawal seizures; taper slowly over weeks-months
- Avoid alcohol completely — severe respiratory depression risk
- Causes drowsiness — do not drive until response known
- Short-term anxiety use only (≤4 weeks) — risk of dependence
- If on opioid painkillers, inform doctor — dangerous combination
- Tolerance can develop for seizure control — inform neurologist if seizures increase
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Clinically reviewed by: Dr. Vikram Sinha, DM (Neurology), Senior Neurologist
Last reviewed: 2026-04-01
References
- BNF — Clonazepam
- ILAE Epilepsy Guidelines
- IAP Epilepsy Guidelines 2024
- NICE Anxiety Guidelines
- FDA Benzodiazepine Black Box Warning 2020