The z-drugs have been used to treat a broad array of sleep problems without sacrificing sleep efficiency. 24 – 26 The prescriber must be aware of the abuse potential of the z-drugs because they may cause stimulation, euphoria, and anxiolysis in some patients, particularly at high dosages. Uncommonly, complex sleep-related behaviors (e.g., sleep driving, sleep eating) have been reported in patients taking high doses of z-drugs this risk should be discussed with patients when these medications are initially prescribed.
23 Like benzodiazepines, the z-drugs have several adverse effects, particularly in higher dosages, including memory loss, dizziness, disinhibition, gastrointestinal upset, and hallucinations. However, unlike benzodiazepines, the z-drugs bind more selectively to certain subunits of the GABA A receptor, primarily targeting the sedative effect of the receptor rather than the anxiolytic effect. 22 Like benzodiazepines, the z-drugs bind to the GABA A receptor, causing hyperpolarization of the cell. 21 Numerous trials have demonstrated the effectiveness of these drugs, including a recent meta-analysis that showed that they decreased sleep latency by an average of 42 minutes vs. The most commonly prescribed class of medication for insomnia is the so-called z-drugs, zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta). Persons with sleep apnea or chronic lung disease with nocturnal hypoxia should be evaluated by a sleep specialist before sedating medications are prescribed. Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition. Although the orexin receptor antagonist suvorexant appears to be relatively effective, it is no more effective than the z-drugs and much more expensive. Benzodiazepines are not recommended because of their high abuse potential and the availability of better alternatives. For those who have difficulty staying asleep, low-dose doxepin and the z-drugs should be considered. For the general population with difficulty falling asleep, controlled-release melatonin and the z-drugs can be considered. Controlled-release melatonin and doxepin are recommended as first-line agents in older adults the so-called z-drugs (zolpidem, eszopiclone, and zaleplon) should be reserved for use if the first-line agents are ineffective. Understanding the risks and benefits of insomnia medications is critical. Although behavioral interventions are the mainstay of treatment, pharmacologic therapy may be necessary for some patients. Insomnia accounts for more than 5.5 million visits to family physicians each year.
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