Switching to Safer Sleep Meds: Timing Matters

Switching off benzodiazepines and z-hypnotics works best in the first year, not the fifth

STUDY: Ayani N et al, Sleep Medicine 2026

STUDY TYPE: Retrospective cohort study

FUNDING: Independent

Background

Benzodiazepine receptor agonists (BZRAs) include traditional benzodiazepines (temazepam, lorazaepam) and z-hypnotics (zolpidem, zaleplon, and eszopiclone).

They work well for insomnia, but long-term use brings dependence, falls, and cognitive fog, especially in older adults. Newer hypnotics, including the orexin blockers suvorexant and lemborexant and the melatonin agonist ramelteon, carry fewer risks. The question is whether adding one of these actually gets patients off their benzodiazepine or just adds a pill.

The Study

• 190 outpatients across two Japanese hospitals who started a novel hypnotic while already on a BZRA hypnotic.
• No control group. Researchers tracked each patient’s own BZRA use before and after starting the novel hypnotic.
• Followed for a median of 12 months.
• Main outcome: did the patient drop at least one BZRA hypnotic?

Results

Just under half (46%) cut back on their BZRA, and 34% stopped it completely. Patients who’d used a BZRA for less than a year succeeded 69% of the time. Those on it a year or more succeeded only 36% of the time. After adjusting for other factors, the odds of successfully cutting back were about a fifth as high in patients with 1 to 5 years of prior use, and a sixth as high with 5 or more years, compared with new or occasional users.

Limitation

No control group, no blinding, retrospective.

Practice Implications

1. When switching to a new hypnotic from a BZRA, cross taper over at least two weeks, and longer if they’ve been on that BZRA for more than a year.
2. Advise patients that they may not feel the new medication the same way. It doesn’t hit as strong, but most of them improve sleep quality with a stronger effect. “Look at how you function the next day, not just how quickly you fall asleep on it.”
3. Unfortunately, it is in older adults where switching to safer sleep meds is most critical, and this is where chronic use of BZRAs is more common.