The clinical use of hypnotics: indications for use and the need for a variety of hypnotics

Abstract

Insomnia may be categorized as difficulty falling asleep, frequent awakening, early awakenings or a combination of each. The ideal hypnotic must promote rapid sleep onset and maintain sleep throughout the night while allowing the patient to awake refreshed the following day. Several benzodiazepines, with differing pharmacokinetic and pharmacodynamic profiles are presently available. All are clinically effective and not only elimination half-life but also dosage prescribed and pattern of distribution are important factors for determining treatment response. Hypnotics have been divided into those with long elimination half-lives (e.g. nitrazepam, flunitrazepam, flurazepam), those with intermediately long half-lives (brotizolam, loprazolam, lormetazepam, temazepam) and those with short half-lives (midazolam and triazolam). Carry-over effects into the morning such as excessive daytime sleepiness or drowsiness are related to drug half-life, dosage and pattern of distribution. In equipotent dosages most controlled clinical trials have found no significant differences between the various benzodiazepine hypnotics. Nevertheless, clinicians in general tend to use long half-life benzodiazepines in patients who have difficulties maintaining sleep and short half-life benzodiazepines for treating sleep onset insomnia. Intermediately long half-life benzodiazepines are used for both indications and most clinicians feel that the choice of hypnotic should not only be influenced by elimination half-life or the dosage used, but by individual patient preference. Hypnotics should be used for only short periods of time and in those patients for whom a more chronic use is indicated, they should be used only on an intermittent basis.

Patterns and correlates of benzodiazepine use in nurses: A nationwide, population‐based study

“…The nurses examined in the present study might have preferred to use this drug to treat sleep problems, which were not responsive to other hypnotics. Previous studies have reported that flunitrazepam should be strictly used on a short‐term basis or in those with long‐term insomnia on an occasional basis (Rickels ). Flunitrazepam can easily lead to drug dependence and benzodiazepine withdrawal syndrome.…”

Medications and Impaired Driving

“…17 For instance, midazolam has a half-life of 1-5 hours whereas diazepam concentrations do not fall to 50% until after about 30-60 hours. 18 In general, a shorter acting BZD is preferred over one that may remain in the body for several days or be metabolized to active metabolites. Nighttime dosing with shorter duration agents may lessen the chance of daytime PDI effects.…”

“…BZDs with longer half-lives may invariably produce carryover effects beyond the dosing period. 17 For instance, midazolam has a half-life of 1 to 5 hours, whereas diazepam concentrations do not fall to 50% until after about 30 to 60 hours. 18 In general, a shorter acting BZD is preferred over one that may remain in the body for several days or be metabolized to active metabolites.…”

Discriminative-Stimulus Effects of Triazolam in Women and Men

“…Benzodiazepines are among the most commonly prescribed psychotherapeutics, indicated for the treatment of insomnia and anxiety, and as an adjunct treatment for epilepsy and some motor disorders (8,9). Women are significantly more likely to be prescribed a benzodiazepine than men (10).…”