Clonazepam Withdrawal and Tinnitus

Introduction to Clonazepam and Tinnitus

• Clonazepam is a long-acting benzodiazepine with an elimination half-life of 30-40 hours, and it is rapidly absorbed after oral administration with a bioavailability of 90%, according to the American Academy of Sleep Medicine 1
• Failure to take clonazepam or dose reduction has resulted in immediate relapse of symptoms, with rapid control restored after resumption of treatment, as reported by the American Academy of Sleep Medicine 1
• Withdrawal from benzodiazepines can cause same-night relapse of symptoms, including tinnitus, as stated by the American Academy of Sleep Medicine 1

Epidemiology of Tinnitus

• Tinnitus is a symptom defined by the perception of sound in the absence of external stimuli, affecting more than 50 million Americans, according to the American College of Radiology 2, 3
• Patients describe tinnitus as various sounds ranging from hissing, buzzing, ringing, pulsations, and clicking to a roaring kind of noise, as described by the American College of Radiology 2, 3
• Primary tinnitus is idiopathic, whereas secondary tinnitus is associated with an underlying cause, as noted by the American College of Radiology 2 and other sources 4
• Subjective tinnitus is perceived by the patient only and comprises 70% to 80% of cases, according to the American College of Radiology 2 and other sources 4
• Sensorineural hearing loss is the most common underlying cause of tinnitus, as reported by sources other than the American College of Radiology 4

Clinical Approach and Management

• Determine if the tinnitus began specifically after the dose reduction of clonazepam, as recommended by the American Academy of Sleep Medicine 1
• Assess if the tinnitus is pulsatile or non-pulsatile, as this helps determine the underlying cause, according to the American College of Radiology 2, 5
• For non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss, imaging studies are generally not recommended, as stated by the American College of Radiology 2, 5
• If the tinnitus is unilateral or asymmetric, or associated with hearing loss, a comprehensive audiological examination is recommended, according to the American College of Radiology 2
• If withdrawal is suspected as the cause, consider stabilizing the clonazepam dose, as studies have shown that failure to take clonazepam results in same-night relapse of symptoms, as reported by the American Academy of Sleep Medicine 1
• For patients experiencing withdrawal symptoms, a gradual tapering schedule is preferred over abrupt discontinuation, as recommended by the American Academy of Sleep Medicine 1
• Consider that many patients are unable to substantially reduce their dose despite periodic attempts at gradual tapering without experiencing prompt reemergence of symptoms, as noted by the American Academy of Sleep Medicine 1
• If the patient cannot tolerate clonazepam or needs to discontinue it, alternative treatments such as melatonin may be considered, as it has fewer side effects, according to the American Academy of Sleep Medicine 1

Monitoring and Follow-up

• Monitor for other withdrawal symptoms such as anxiety, insomnia, and irritability, as recommended by the American Academy of Sleep Medicine 1
• Be aware that clonazepam side effects can include sedation, impotence, early morning motor incoordination, confusion, and memory dysfunction, as reported by the American Academy of Sleep Medicine 1
• Recognize that clonazepam at 0.5 to 1.0 mg can be associated with the possible risk of developing or worsening sleep apnea, according to the American Academy of Sleep Medicine 1
• If the tinnitus persists despite addressing the withdrawal, consider other etiologies and appropriate evaluations, as recommended by the American College of Radiology 2, 5