Should I use zopiclone or Sublinox for insomnia?

Zolpidem (Sublinox) vs. Zopiclone for Insomnia

For insomnia treatment, zolpidem (Sublinox) is preferred over zopiclone for sleep onset insomnia, while eszopiclone (the S-isomer of zopiclone) is recommended for sleep maintenance insomnia. 1, 2

Medication Selection Algorithm

For Sleep Onset Insomnia:

• First-line: Zolpidem 10mg (5mg in elderly) 2

  • Sublingual zolpidem (Sublinox) provides more rapid onset than oral zolpidem 3
  • Significantly reduces latency to persistent sleep compared to oral formulations
  • Bioequivalent to oral zolpidem with similar overall tolerability profile

• Alternatives:

  • Zaleplon 10mg 2
  • Ramelteon 8mg 2
  • Triazolam 0.25mg 1

For Sleep Maintenance Insomnia:

• First-line: Eszopiclone 2-3mg 1, 2

  • Improves total sleep time by 28-57 minutes compared to placebo
  • Reduces wake after sleep onset by 10-14 minutes
  • Moderate-to-large improvement in sleep quality

• Alternatives:

  • Doxepin 3-6mg 2
  • Temazepam 15mg 2
  • Suvorexant 10-20mg 2

Efficacy Comparison

Zolpidem (Sublinox):

• Effectively reduces sleep onset latency 2
• Improves total sleep time by approximately 29 minutes versus placebo 2
• Reduces wake after sleep onset by 25 minutes 2
• Sublingual formulation shows faster onset than oral formulation 3

Zopiclone/Eszopiclone:

• Eszopiclone effectively improves both sleep onset and maintenance 1
• Improves total sleep time by 28-57 minutes compared to placebo 2
• Reduces wake after sleep onset by 10-14 minutes 2
• Zopiclone has shown efficacy equivalent or greater than several benzodiazepines 4

Safety Considerations

Zolpidem (Sublinox):

• Common adverse effects include headache and dry mouth 3
• Sublingual formulation is generally well-tolerated with most adverse events being mild to moderate 3

Zopiclone/Eszopiclone:

• Most common adverse effect is bitter taste (reported by <10% of users) 4
• Other common adverse effects include headache and dry mouth 5
• Low risk of rebound insomnia and withdrawal reactions at therapeutic doses 4
• Very low dependency potential 4

Special Populations

Elderly Patients:

• Lower doses recommended: zolpidem 5mg, eszopiclone 1-2mg 1, 2, 6
• Ramelteon or low-dose doxepin may be preferred due to lower risk of falls and cognitive impairment 2

Hepatic Impairment:

• Eszopiclone: Do not exceed 2mg in severe hepatic impairment 6
• No dose adjustment needed for mild-to-moderate hepatic impairment 6

Renal Impairment:

• No dose adjustment necessary for eszopiclone as less than 10% is excreted in urine as parent drug 6

Substance Use History:

• Non-scheduled options like ramelteon or doxepin may be preferred 2

Drug Interactions

• Eszopiclone is metabolized by CYP3A4 and CYP2E1 6
• Potent CYP3A4 inhibitors (e.g., ketoconazole) can increase eszopiclone exposure 2.2-fold 6
• No significant pharmacokinetic interactions with paroxetine, digoxin, or warfarin 6

Clinical Decision Points

1. For sleep onset insomnia: Choose zolpidem (Sublinox) for its rapid onset of action
2. For sleep maintenance insomnia: Choose eszopiclone for its effectiveness in reducing nighttime awakenings
3. For both onset and maintenance issues: Eszopiclone may be preferred as it addresses both problems
4. For elderly patients: Use lower doses and consider alternatives with lower risk profiles
5. For patients with morning activities: Consider shorter-acting agents like zolpidem

Important Caveats

• Both medications should be used for short-term treatment (generally ≤4 weeks) 4, 7
• The lowest effective dose should be used to minimize adverse effects 5
• Taking eszopiclone with or immediately after a high-fat meal may reduce its effect on sleep onset 6
• Cognitive behavioral therapy for insomnia (CBT-I) should be considered alongside or before medication 2

While both medications are effective for insomnia, the choice between zolpidem (Sublinox) and zopiclone should be based on whether the primary issue is sleep onset or maintenance, patient age, and potential drug interactions.