What's the next step for a 57-year-old female (YOF) patient taking 10mg Dayvigo (lemborexant) and 5mg zopiclone at hour of sleep (HS) for insomnia, who can fall asleep better with Dayvigo but still has trouble staying asleep while trying to wean off zopiclone?

Management of Insomnia in a 57-Year-Old Female Taking Dayvigo and Zopiclone

For a 57-year-old female patient who can fall asleep with Dayvigo (lemborexant) but has trouble staying asleep while trying to wean off zopiclone, the recommended approach is to increase the Dayvigo dose to 10mg (if currently on 5mg) or consider adding a low-dose doxepin (3-6mg) for sleep maintenance while continuing to taper zopiclone gradually. 1

Current Situation Assessment

The patient is currently taking:

• Dayvigo (lemborexant) 10mg at bedtime - helping with sleep onset
• Zopiclone 5mg at bedtime - in process of weaning
• Current issue: Can fall asleep but has trouble staying asleep

Treatment Options for Sleep Maintenance

Option 1: Optimize Dayvigo (First-line)

• Ensure the patient is taking the full 10mg dose of Dayvigo
• Lemborexant has demonstrated efficacy for both sleep onset and sleep maintenance insomnia 2
• Lemborexant has the highest probability of being the best treatment for total sleep time and sleep efficiency compared to other insomnia medications 2
• Has minimal next-day residual effects, with studies showing no significant impairment in next-day functioning 3

Option 2: Add Low-Dose Doxepin (3-6mg)

• If Dayvigo optimization is insufficient, consider adding low-dose doxepin
• Doxepin at 3-6mg is specifically effective for sleep maintenance insomnia 1
• Can be used concurrently while completing zopiclone taper

Option 3: Consider Eszopiclone

• If other options fail, eszopiclone 2-3mg has demonstrated effectiveness for sleep maintenance 1
• However, this would mean switching from one "Z-drug" (zopiclone) to another, which may not be ideal when trying to reduce dependence on this class

Zopiclone Tapering Strategy

1. Continue gradual tapering of zopiclone:

   • Reduce by 1.25mg every 1-2 weeks (can cut 5mg tablets)
   • Alternatively, reduce frequency to every other night before further dose reduction
   • Schedule follow-up within 7-10 days after each dose reduction 1

2. Monitor for withdrawal symptoms:

   • Rebound insomnia
   • Anxiety
   • Irritability
   • Tremor

Non-Pharmacological Interventions

While optimizing medication, implement these evidence-based strategies:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I):

   • Strongly recommended by the American College of Physicians as first-line treatment 4, 1
   • Components include sleep restriction, stimulus control, cognitive therapy, and sleep hygiene

2. Sleep Hygiene Optimization:

   • Regular sleep-wake schedule
   • Avoid heavy meals throughout the day and alcohol use
   • Create a sleep-conducive environment 4

3. Relaxation Techniques:

   • Progressive deep muscle relaxation
   • Mindfulness-based techniques 1

Monitoring and Follow-up

• Schedule follow-up within 7-10 days to evaluate treatment response 1
• Assess for adverse effects of Dayvigo, particularly somnolence which is the most common side effect 3, 5
• Monitor for any drug interactions, especially if the patient is on other medications that may interact with lemborexant 6

Cautions and Considerations

• Avoid alcohol use with Dayvigo or zopiclone due to additive CNS depressant effects 7
• Be aware that complex sleep behaviors (sleep-driving, sleep-eating) can occur with sedative-hypnotics, though less commonly with Dayvigo than with zopiclone 7
• Dayvigo has a better safety profile regarding next-morning impairment compared to zopiclone 3

By implementing this approach, the patient should experience improved sleep maintenance while successfully completing the zopiclone taper, ultimately achieving better quality sleep with minimal medication burden.