4.1.1 Hypnotics

Choice

Drug

Dosage
1st choiceNon-drug treatment
2nd choicesZolpidem 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

Or
Temazepam tablets 10mg, 20mgDose:
Usually 10-20mg at bedtime;
Elderly 10mg at bedtime, alternatively 20 mg at bedtime, higher dose only to be administered in exceptional circumstances

Prescribing Notes

  • Non-drug treatments recommended as first-line interventions include sleep hygiene and stimulus control advice. A range of resources are available on the Patient Zone and the Choice and Medication website
  • Hypnotics should be used in short courses only (review after 1 week) when insomnia is severe, disabling or subjecting the individual to extreme distress
  • Maximum recommended doses should not be exceeded
  • 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
  • Existing patients receiving a hypnotic should be reviewed and offered the chance to stop or reduce. See 4.10c and resources on the primary care intranet
  • 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.
  • Please note high cost of benzodiazepine liquids e.g. nitrazepam suspension costs £114 per 70ml (Nov 19)
  • Promethazine is sometimes used (prescribed or purchased OTC) as a perceived ‘safer’ alternative to benzodiazepines in the short-term management of insomnia. It can cause severe anticholinergic effects, particularly in elderly patients and when taking other anticholinergic drugs in combination. Refer to ‘Anticholinergic Burden’ resources.  Prescribers should be aware that use may lead to hangover drowsiness the following day and its sedative effects may diminish after a few days of continued treatment

Cautions

  • Clinicians should be mindful of the risks associated with prescribing benzodiazepines and impact of co-prescribed medicines and co-morbidities. The risk of diversion and misuse of prescribing medicines along with illicit use should also be considered
  • Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. See MHRA
  • 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