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Guidance on switching, tapering, and discontinuation of insomnia medications

Guidance on switching, tapering, and discontinuation of insomnia medications
  Switching to different class* Within-class switching* Discontinuation best practices
Benzodiazepines

Estazolam

Flurazepam

Lorazepam

Temazepam

Triazolam

 Slow taper method/cross taper Direct switch
  • Tapering is medically necessary for patients taking excessively high doses
  • Reduce dose by 10-25% increments at intervals of 1 to several weeks
Nonbenzodiazepine BZRAs
Eszopiclone Taper and then wait 1 to 2 days Taper and then wait 1 to 2 days
  • Tapering is medically necessary for patients taking excessively high doses
  • Reduce dose by 25% each week
Zaleplon Direct switch Direct switch
Zolpidem Taper and then wait 1 to 2 days Taper and then wait 1 to 2 days
Dual orexin receptor agonists
Daridorexant Direct switch Direct switch
  • No evidence for substantial or consistent rebound upon discontinuation
  • Data do not support the need for a taper or other measures to ensure safety
Lemborexant Direct switch Direct switch
Suvorexant Direct switch Direct switch
Other agents
Doxepin 3 to 6 mg Direct switch N/A
  • No evidence for substantial or consistent rebound upon discontinuation
  • Data do not support the need for a taper or other measures to ensure safety
Ramelteon Direct switch N/A
Antidepressants
Amitriptyline Slow taper method/cross taper Not recommended
  • Withdrawal syndrome is well described with rapid discontinuation of antidepressants (insomnia, flu-like symptoms, mood disturbances)
  • Gradually reduce the dose in accordance with each drug's prescribing informationΔ
Mirtazapine Slow taper method/cross taper Not recommended
Trazodone Slow taper method/cross taper Not recommended

BZRA: benzodiazepine receptor agonist; CBT-I: cognitive behavioral therapy for insomnia.

* Methods of switching are defined as follows:

  • Slow taper: Gradual dose reduction of insomnia drug, with lowering by increments every few days, usually over a period of 4 weeks, with the goal of discontinuing the medication. Duration and success depend on drug dosage, pharmacologic properties, and patient response to the decreased dose.
  • Cross taper: The first insomnia drug dose is reduced while a new insomnia medication is introduced at a low dose and gradually increased. This can only be safely done with medications that have no interaction.
  • Taper and wait 1 to 2 days: Similar to the slow taper method of gradually decreasing the dose until discontinuation, followed by a withholding period of 1 to 2 days before any new insomnia medication is started. This can be due to the insomnia treatment having a longer half-life and needing time to be cleared from the system prior to initiating new therapies.
  • Direct switch: The first insomnia drug is stopped, and a new insomnia drug is commenced the next day at the usual therapeutic dose. There can be considerable risk of withdrawal symptoms and drug interactions.

¶ In general, people want to be informed of alternative strategies for managing their insomnia if they are being advised to stop their present hypnotic. The deprescribing plan may be more successful if the individual is fully educated about what to expect during discontinuation. The introduction of CBT-I may also be helpful in transitioning people off hypnotic medications.

Δ Refer to separately available content in UpToDate on switching and discontinuing antidepressant medications for more detailed recommendations.

Adapted from: Watson N, Benca R, Krystal A, et al. Alliance for Sleep clinical practice guideline on switching or deprescribing hypnotic medications for insomnia. J Clin Med 2023; 12:2493.
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