What are the recommendations for using Lunesta (eszopiclone) for insomnia?

Eszopiclone (Lunesta) for Insomnia Treatment

Eszopiclone is recommended for treating sleep maintenance insomnia with moderate improvements in sleep quality, but should be used with caution due to potential side effects including next-morning impairment.

Efficacy and Indications

• Eszopiclone is FDA-approved for the treatment of insomnia, with clinical trials supporting efficacy for up to 6 months 1
• The American Academy of Sleep Medicine provides a weak recommendation for eszopiclone specifically for sleep maintenance insomnia 2
• At recommended doses (2-3 mg for adults, 1-2 mg for elderly), eszopiclone significantly:
  • Decreases sleep latency (time to fall asleep)
  • Improves sleep maintenance (measured as wake time after sleep onset)
  • Increases total sleep time by 28-57 minutes compared to placebo 2

Dosing Recommendations

• Adults (18-64 years): 2-3 mg taken immediately before bedtime 1
• Elderly patients (≥65 years): 1-2 mg taken immediately before bedtime 1
• The 1 mg dose is primarily for sleep onset in older adults whose main complaint is difficulty falling asleep 1
• Must be taken only when able to get a full night's sleep (7-8 hours) 1

Side Effects and Safety Concerns

• Common side effects include:

  • Unpleasant taste in mouth (most common)
  • Drowsiness
  • Dizziness
  • Headache 1

• Serious concerns include:

  • Next-morning psychomotor and memory impairment that can last up to 11.5 hours after dosing 2, 1
  • Potential for complex sleep behaviors (sleep-walking, sleep-driving) 1
  • Confusion reported in 3% of patients taking 3 mg dose 2
  • Memory impairment reported in 1-1.5% of patients 2
  • Risk of dependence (Schedule IV controlled substance) 1

Special Populations

• Elderly patients:

  • Should use lower doses (1-2 mg) due to increased sensitivity 1
  • 2.5% of elderly patients reported confusion with 2 mg dose 2

• Patients with substance use history:

  • Use with caution due to dependence potential 3
  • Consider non-scheduled alternatives like ramelteon or doxepin 3

Comparative Efficacy

• Eszopiclone has not been directly compared with other non-benzodiazepine hypnotics in well-designed trials 4
• Unlike most other hypnotics, eszopiclone is not limited to short-term use 5, 6
• A cost-utility analysis suggested eszopiclone is cost-effective for primary insomnia treatment in the US 6

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks after initiating treatment to evaluate effectiveness 3
• Monitor for side effects, particularly:
  • Daytime sedation
  • Falls
  • Cognitive changes 3
• No evidence of tolerance during 12 months of treatment 6
• No rebound insomnia or serious withdrawal effects upon discontinuation 6

Important Precautions

• Do not take with alcohol or other sedating medications 1
• Do not take unless able to get a full night's sleep (7-8 hours) 1
• Take immediately before bedtime, not earlier 1
• Driving ability and clear thinking may be impaired the morning after taking eszopiclone 1

Alternative Approaches

• Consider cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment before medication 3
• For patients concerned about dependence, alternatives like ramelteon or low-dose doxepin may be preferable 3

Remember that while eszopiclone can be effective for insomnia, the benefits must be weighed against potential risks, particularly in elderly patients and those with a history of substance use.