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Nonbenzodiazepine benzodiazepine receptor agonists (BZRAs) in the management of insomnia in adults

Nonbenzodiazepine benzodiazepine receptor agonists (BZRAs) in the management of insomnia in adults
Nonbenzodiazepine Clinical use* Preparations (brand name) Adult dose
(initial)
Adult dose
(max)
Dose in older adults
(≥65 years)
Half-life
(hours)
Potential for drug interactionsΔ
Eszopiclone Sleep onset or sleep maintenance insomnia Tablet (Lunesta) 1 mg 3 mg 1 to 2 mg Intermediate (6)

Moderate

Eszopiclone is metabolized in part by CYP3A4
Zaleplon Sleep onset insomnia Capsule (Sonata) 5 mg 20 mg 5 mg Short (1) Low
Zolpidem Sleep onset or sleep maintenance insomnia Tablet (Ambien), sublingual tablet (Edluar), oral liquid (Zolpimist; 5 mg per spray)

Males 5 to 10 mg

Females 5 mg
10 mg 5 mg Short (1.4 to 4.5)

Low to moderate

Zolpidem is metabolized in part by CYP3A4

Metabolized more slowly by females, particularly with age
Zolpidem extended release Sleep onset or sleep maintenance insomnia Coated tablet (Ambien CR)

Males 6.25 to 12.5 mg

Females 6.25 mg
12.5 mg 6.25 mg Intermediate (1.6 to 4)
Zolpidem middle of the night Sleep maintenance insomnia (middle of the night) Sublingual tablet (Intermezzo; 1.75 mg, 3.5 mg)

Males 3.5 mg

Females 1.75 mg
3.5 mg 1.75 mg Short (1.4 to 4.5)
Zopiclone (not available in the United States) Sleep onset or sleep maintenance insomnia Tablet 3.75 mg 7.5 mg 3.75 mg  Intermediate (5 to 7)

Moderate

Zopiclone is metabolized by CYP2C8 and 3A4
* Appropriate clinical uses may differ from the US Food and Drug Administration (FDA)-approved indication(s) for a given drug.
¶ Initiate treatment using lowest dose shown for those with low body weight, debilitated patients, and those receiving treatment with opioid analgesics or other central nervous system or cardiorespiratory depressants.
Δ For specific drug interactions, including management recommendations and combinations that should be avoided, use Lexi-Interact drug interactions program included with UpToDate.
◊ Duration of effect longer than predicted by half-life due to sustained release.
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