Management of insomnia

Refer to

Before commencing a hypnotic

Review current medicines for ones that are associated with insomnia or a disturbed night's sleep. Examples include MAOIs, SSRIs, SNRIs, lamotrigine, aripiprazole, steroids, beta blockers, diuretics, statins and laxatives. Consider changing the time the person takes these to an earlier time in the day so as to hopefully prevent problems at night.

Try to ascertain if there is a physical reason for the insomnia such as pain or whether insomnia is secondary to an undiagnosed mental health disorder, and treat this appropriately (a WHO survey of people reporting sleep problems identified that 52% had a well-defined mental health disorder and 54% reported a physical disorder).

Remember: Hypnotics can provide relief from symptoms of insomnia but they do not treat any underlying cause.

Drug therapy should be avoided if at all possible. Good sleep hygiene is the cornerstone of any treatment plan for insomnia. This includes:

  • Increase daily exercise but not in the evening.
  • Reduce daytime napping.
  • Avoid caffeine and alcohol before bedtime.
  • Do not watch TV in bed.
  • Use anxiety management or relaxation techniques.
  • Develop a regular routine of rising and retiring at the same time each day.

Psychological therapies (CBT) have also been shown to be effective in the management of persistent insomnia but are beyond the scope of this guideline.

General prescribing principles

  1. Pharmacological treatment should only be used as a last resort.
  2. Choice of hypnotic should be made based on individual preference where appropriate and use the least expensive agent where possible.
  3. Treatment should be for a maximum of four weeks including any tapering-off period.
  4. If there is an inadequate response to one hypnotic there is no evidence any other will help.
  5. Prescribers must warn individuals about the risk of drowsiness the next day and to avoid driving when affected.
  6. The prescribing of hypnotics to children is not justified (with the exception of occasional use for conditions such as night terrors and somnambulism). Treatment with melatonin should only be initiated by or on the recommendation of a CAMHS or Learning Disability specialist.
  7. Antipsychotics should not be used to treat insomnia (but insomnia may improve in response to adequate treatment of a psychotic episode with antipsychotics).
  8. Antidepressants should not be used to treat insomnia (but insomnia may improve in response to adequate treatment of a depressive episode). Low dose amitriptyline is sometimes used to treat insomnia but where there is no relevant co-morbidity (e.g. neuropathic pain) it should not be used as tolerance is quickly developed to the sedating effects and the relative side effects are unfavourable compared to the preferred hypnotics above.
  9. Some individuals may wish to try alternative remedies and care should be taken to ensure these are safe for the individual with no interactions with their medicines or illnesses. They are not available through the NHS.

Prescribing in secondary care

Patients may need to take a hypnotic whilst they are in hospital. In order to avoid patients inadvertently continuing on hypnotics once discharged from hospital it has been agreed that patients discharged from local hospitals will not receive a supply of benzodiazepines unless it can be clearly established that they have been taking these long-term and a supply is needed.

Prescribers in secondary care are requested to review all prescriptions for hypnotics on discharge for appropriateness and ensure there is clear communication for GPs regarding whether hypnotics should not be continued once discharged.

Where a specialist recommends that treatment with a hypnotic is continued past the usual maximum of 4 weeks (i.e. off-licence prescribing) a clear rationale must be communicated to the GP, including a proposed treatment plan of when to review, reduce and/or discontinue treatment.

Long term hypnotics

It is recognised that a number of patients are receiving long-term hypnotics. This is an unlicensed use and the prescriber needs to ensure that they fully consider the implications of prescribing an unlicensed medication.

The patient's record should show that patients receiving a long-term benzodiazepine have:

  • been advised on appropriate non-drug therapies
  • been given appropriate advice on the risks, including the potential for dependence. If over 65 this should include information on the risk of falls and cognitive impairment.
  • had a regular medication review (e.g. every 3 months)
  • been offered the opportunity to be supported to stop taking the hypnotic (see below).

When individuals are prescribed hypnotics long term they should be offered the opportunity to withdraw from their treatments. This must be done collaboratively to produce the most success. The prescription should be converted to an equivalent dose of diazepam to facilitate a gradual reduction in dose, using liquid preparations where necessary. Commonly used benzodiazepine equivalent doses (not necessarily hypnotics) are listed below. Aim for a reduction of 10-20% of the dose every 1-2 weeks and adjust the rate according to the individual's response.

Zopiclone 7.5mg

  • Diazepam equivalent = 5mg

Zolpidem 10mg

  • Diazepam equivalent = 5mg

Temazepam 20mg

  • Diazepam equivalent = 10mg

Nitrazepam 5mg

  • Diazepam equivalent = 5mg (may be less, use caution)

Lormetazepam 1mg

  • Diazepam equivalent = 5mg

Clonazepam 2mg

  • Diazepam equivalent = 2.5mg - 40mg (Caution: huge potential inter-person variability)

Lorazepam 1mg

  • Diazepam equivalent = 5mg - 10mg

Oxazepam 15mg

  • Diazepam equivalent = 5mg

This patient letter that has been shown to result in reduced consumption of benzodiazepines. Practices may wish to adapt this letter to suit their needs.


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