Lunesta Dosing
For most non-elderly adults with chronic insomnia, start Lunesta (eszopiclone) at 2 mg immediately before bedtime, and increase to 3 mg if sleep maintenance is the primary problem. 1
Dosing by Patient Population
Non-Elderly Adults (18-64 years)
- Starting dose: 2 mg at bedtime 1
- May increase to 3 mg if clinically indicated, particularly for sleep maintenance difficulties 1
- The 3 mg dose is more effective for maintaining sleep throughout the night 2
Elderly Patients (≥65 years)
The dosing strategy differs based on the specific sleep complaint:
For difficulty falling asleep (sleep onset): Start with 1 mg at bedtime 1, 3
- May increase to 2 mg if needed 1
For difficulty staying asleep (sleep maintenance): Start with 2 mg at bedtime 1, 3
- Do not exceed 2 mg in elderly patients 1
Special Populations Requiring Dose Reduction
Start at 1 mg and do not exceed 2 mg in:
- Patients with severe hepatic impairment 1
- Patients taking potent CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin, ritonavir) 1
Evidence Supporting These Doses
The 2017 AASM guideline recommends eszopiclone for both sleep onset and sleep maintenance insomnia based on trials using 2 mg and 3 mg doses 2. The evidence shows:
- 2 mg dose: Improved total sleep time by 28-57 minutes and reduced wake after sleep onset by 10-14 minutes compared to placebo, with moderate-to-large improvements in sleep quality 2
- 3 mg dose: Demonstrated clinically significant reductions in objective sleep latency and increased total sleep time by similar margins 2
Administration Timing
Take immediately before bedtime on an empty stomach 1. Taking Lunesta with or immediately after a heavy, high-fat meal delays absorption by approximately 1 hour and reduces effectiveness for sleep onset 1.
Duration of Treatment
Unlike older hypnotics, eszopiclone is not restricted to short-term use and has been studied for up to 6 months of nightly administration without evidence of tolerance or rebound insomnia 2, 4. This represents a key advantage over zolpidem and zaleplon, which are limited to short-term use 5.
Common Pitfalls to Avoid
- Don't underdose elderly patients with sleep maintenance problems - they need 2 mg, not 1 mg 1, 3
- Don't give with food - this significantly delays onset of action 1
- Don't forget dose adjustment with CYP3A4 inhibitors - failure to reduce dose increases risk of adverse effects 1
- Don't exceed 2 mg in elderly or hepatically impaired patients - higher doses increase fall risk and cognitive impairment 1
Most Common Adverse Effects
The most frequently reported side effects are unpleasant/bitter taste (17-34% depending on dose), followed by headache, dizziness, dry mouth, and somnolence (4-9%) 6, 7, 8. These are generally dose-dependent and well-tolerated 4.