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# Clobazam (Oral)
## Overview
Clobazam is a 1,5-benzodiazepine with anticonvulsant properties. Unlike 1,4-benzodiazepines, it has a more favorable profile regarding sedation and cognitive impairment. It is a Schedule IV controlled substance.
## Primary Indications
Adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome (LGS). Note: Off-label use for refractory epilepsy is common.
## Adult Dosing
Initiate at 10 mg/day. After 7 days, increase to 20 mg/day. If well-tolerated, may increase up to 40 mg/day. Doses >20 mg/day should be administered in two divided doses.
## Pediatric Dosing (≥2 Years)
Dosing is weight-based for patients ≤30 kg:
* **Initial:** 5 mg/day.
* **Titration:** After 7 days, increase to 10 mg/day. If tolerated, may increase to 20 mg/day max.
* **Patients >30 kg:** Follow adult dosing guidelines (initial 10 mg/day; target 20 mg/day; max 40 mg/day).
* **Divided Dosing:** Doses exceeding 5 mg/day (for ≤30 kg) or 20 mg/day (for >30 kg) should be administered in two divided doses.
## Dose Adjustments
* **Renal Impairment:** No specific adjustment required; use with caution.
* **Hepatic Impairment:** Use with caution. In moderate to severe impairment (Child-Pugh B or C), start at 5 mg/day and titrate more slowly.
* **CYP2C19 Poor Metabolizers:** Exposure to active metabolite (N-desmethylclobazam) is increased; initiate at 50% of recommended dose and titrate slowly.
## Contraindications
Hypersensitivity to clobazam or any product component.
## Adverse Effects
* **Common:** Somnolence, pyrexia, lethargy, drooling (sialorrhea), constipation, ataxia, behavioral changes (aggression/irritability).
* **Serious:** Severe skin reactions (SJS/TEN), respiratory depression, physical/psychological dependence, suicidal ideation.
## Key Drug Interactions
* **CYP2C19 Inhibitors (e.g., fluconazole, fluvoxamine):** May significantly increase clobazam levels.
* **CNS Depressants:** Additive sedation and respiratory depression (alcohol, opioids).
* **Anticonvulsants:** May increase phenytoin levels; may decrease carbamazepine or valproate levels; requires close titration.
* **Oral Contraceptives:** May decrease the efficacy of hormonal contraceptives.
## Monitoring
* **Clinical:** Monitor for excessive sedation, behavioral changes, suicidal ideation, and signs of respiratory depression.
* **Dermatological:** Monitor for rash, blistering, or mucosal lesions (risk of SJS/TEN).
* **Laboratory:** Not generally required, but monitor LFTs in patients with pre-existing hepatic impairment.
## Clinical Pearls
* **Gradual Withdrawal:** Never discontinue abruptly due to risk of status epilepticus and withdrawal seizures; taper over at least 2–4 weeks.
* **N-desmethylclobazam:** Clobazam is metabolized to an active metabolite with a long half-life, leading to steady-state concentrations being reached only after 5–9 days. Titrate slowly to account for this.
* **Suspension:** The oral suspension should be shaken well before each use.
* **Documentation:** Verify current weight-based protocols, as clinical practice regarding titrations vary by institution.
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**Educational Disclaimer:** This information is for educational purposes only and does not replace professional clinical judgment. Always consult the most current official prescribing information (package insert) and institutional guidelines before prescribing or administering medication.
