4.1.1 Hypnotics

ChoiceDrugDosage
1st choiceNon-drug treatment
2nd choicesTemazepam tablets 10mg, 20mg; oral solution 10mg/5mlDose:
Usually 10-20mg at bedtime
Or
Zolpidem tablets 5mg, 10mg

Dose:
10mg at bedtime; elderly (or debilitated) 5mg

Or
Zopiclone tablets 3.75mg, 7.5mg

Dose:
7.5mg at bedtime; elderly initially 3.75mg at bedtime increased if necessary
Note: In patients with chronic pulmonary insufficiency an initial dose of 3.75mg is recommended

Prescribing Notes

  • Non-drug treatments recommended as first-line interventions include sleep hygiene and stimulus control advice.
  • Hypnotics should be used in short courses only when insomnia is severe, disabling or subjecting the individual to extreme distress.
  • Hypnotics can affect ability to drive or operate machinery; they also increase the effects of alcohol. Moreover the hangover effects of a night dose may impair driving on the following day
  • New patients should not be put on a repeat prescription system and existing patients receiving a hypnotic should be reviewed and offered the chance to stop or reduce (see BNF withdrawal protocol).
  • Patients should be advised about the benefits and harms of hypnotics. For every 13 people aged 60 years or over, treated with a hypnotic:
    • About one person will sleep better. This means that, on average, they will get an extra 25 minutes sleep each night and will wake up once less often every two nights. The hypnotic will have no benefit for the other 12 people.
    • About two people will have adverse effects such as drowsiness, fatigue, headaches, nightmares, nausea or GI disturbances.

Cautions

  • Withdrawal of hypnotic and anxiolytic drugs should be gradual because abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens.
  • Hypnotics and anxiolytics should be avoided in older patients if possible. Older patients can become ataxic, confused and are at increased risk of falls and fractures.
  • All benzodiazepines are capable of being fatal in overdose but are particularly dangerous if combined with other CNS depressants such as alcohol. Care should be taken when prescribing for patients at high risk of overdose.
  • Avoid the use of nitrazepam in the elderly as it has a prolonged action and may give rise to residual effects on the following day; repeated doses tend to accumulate.
  • The use of benzodiazepines in dementia is associated with increased mortality and their use should be a last resort. Insomnia is common in patients with dementia – zolpidem may be a preferred option.