Best Practice

In 1988, the Committee on Safety of Medicines first advised that benzodiazepine hypnotics should be used only if insomnia is severe, disabling or causing the person extreme distress. The lowest dose that controls symptoms should be used, for a maximum of 4 weeks and intermittently if possible20. The Medicines and Healthcare products Regulatory Agency (MHRA) reinforced these recommendations in the July 2011 edition of Drug Safety Update46.

The NICE technology appraisal on zaleplon, zolpidem and zopiclone recommends that when, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications63.

UK guidance and recommendations for use of hypnotics – benzodiazepines and Z-drugs

  • Committee for Safety of Medicines (CSM)20

    • Benzodiazepines should be used only in cases of severe, disabling insomnia where the patient is suffering from extreme stress.
    • The lowest dose should be used for a maximum of four weeks.
    • Intermittent use is recommended.
    • The patient should be tapered off the treatment gradually.
  • Medicines and Healthcare products Regulatory Agency (MHRA)46

    • Given the risks associated with the use of benzodiazepines, patients should be prescribed the lowest effective dose for the shortest time possible. Maximum duration of treatment should be 4 weeks, including the dose-tapering phase.
  • National Institute for Health and Care Excellence (NICE)

    • Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling62.
    • Therapy is only considered appropriate for the management of severe insomnia interfering with normal daily life63.
    • Hypnotics should be prescribed for short periods of time only, in strict accordance with licensed indications63.
    • There is a lack of compelling evidence to distinguish between the Z-drugs or the shorter-acting benzodiazepines, the drug with the lowest purchase cost should be prescribed. Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others63.
    • Review and, if appropriate, revise prescribing of hypnotics to ensure that it is in line with national guidance64.
  • British National Formulary (BNF)11

    • Benzodiazepines and the Z–drugs should be avoided in the elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury.

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