Some hypnotics can be stopped without a taper, and others require caution
STUDY: Watson NF et al, Journal of Clinical Medicine 2023
STUDY TYPE: Clinical practice guideline (systematic review with expert consensus)
FUNDING: Idorsia Pharmaceuticals (manufacturer of daridorexant, an orexin-antagonist)
Background
Insomnia meds are often switched, and these guidelines look at how to make these transitions safely.
The Process
- Five sleep medicine specialists from the Alliance for Sleep graded the evidence regarding stopping and switching hypnotics.
Review
Benzodiazepines, z-hypnotics, antidepressants (eg, trazodone), antipsychotics (eg, quetiapine), and gabapentinoids (eg, gabapentin, pregabalin) should be tapered off gradually after medium- or long-term use (> 2 weeks). Lower the dose by 10-25% per week. Ideally, add CBT-insomnia during the taper.
Trazodone and quetiapine both produced withdrawal symptoms, including nausea, dizziness, and occasional rebound insomnia, in case reports.
When switching from a z-hypnotic, rebound insomnia is possible but brief with zolpidem and eszopiclone, allowing a 1-2 day taper. Rebound insomnia is unlikely with the short half-life zaleplon. Two large randomized triales compared discontinuation effects of zaleplon and zolpidem, finding rebound insomnia with zolpidem but not zaleplon.
Orexin antagonists, low-dose doxepin, and ramelteon do not show meaningful rebound or withdrawal in trials, so direct switching from these works without special precautions.
The Data
Practice Implications
- Older sleep medicines (benzodiazepines and z-hypnotics) are limited because of tolerance, falls, and possibly cognitive impairment. They also lack meaningful improvements in sleep quality.
- Newer agents (ramelteon, orexin-antagonists) are safer, have no known tolerance, and may improve sleep quality.
- Tolerance is not the only reason that switching from old to new is difficult. The newer medications lack the subjective effects of the old — an anxiolytic, rewarding, “turn my ruminating mind off” feeling.
- This paper is a start, but the strategy is best personalized to the patient. Some trials successfully switch from older meds to orexin antagonists through a one month cross-taper.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
