Zolpidem (Ambien) Dosing Recommendations for Insomnia
For the treatment of insomnia, zolpidem (Ambien) is recommended at a dose of 10 mg for adults and 5 mg for elderly patients or those with hepatic impairment, taken once daily immediately before bedtime. 1, 2, 3
Standard Dosing Guidelines
Immediate-Release Formulation
- Adults (under 65 years): 10 mg once daily at bedtime
- Elderly (65+ years): 5 mg once daily at bedtime
- Patients with hepatic impairment: 5 mg once daily at bedtime
Extended-Release Formulation
- Adults: 12.5 mg once daily at bedtime (reduced from original recommendation)
- Elderly/hepatic impairment: 6.25 mg once daily at bedtime
Clinical Considerations
Efficacy for Different Insomnia Types
Duration of Treatment
- FDA-approved for short-term treatment (≤4 weeks) 5
- The American Academy of Sleep Medicine suggests zolpidem can be used for chronic insomnia (weak recommendation) 1
- No evidence of tolerance developing in studies up to 6 months, though isolated cases of tolerance have been reported with high doses used for several years 5
Important Prescribing Considerations
Pharmacokinetics
- Rapid onset of action
- Half-life: 2.5-3 hours
- Metabolized primarily via CYP3A4 with minor pathways through CYP1A2, 2C9, 2C19, and 2D6 4
Safety Profile
- Most common adverse events: nausea, dizziness, drowsiness 5, 6
- Potential for anterograde amnesia, particularly at doses above 10 mg 3
- Low potential for rebound insomnia when used as recommended 5
Special Formulations
- ZolpiMist: Oral spray formulation, each metered spray contains 5 mg 7
- Adults: 2 sprays (10 mg)
- Elderly/hepatic impairment: 1 spray (5 mg)
Common Pitfalls and Caveats
FDA Dosage Adjustment: Note that the FDA has lowered the recommended starting dosage of immediate-release zolpidem from 10 mg to 5 mg for adults and from 12.5 mg to 6.25 mg for extended-release formulations 1
Next-Day Impairment: While zolpidem has fewer next-day effects than some other hypnotics, it can still cause impairment in psychomotor performance, particularly at higher doses 3, 5
Medication Interactions: Use caution when combining with other CNS depressants or medications metabolized through the same CYP450 pathways 4
Dependence Risk: While lower than benzodiazepines, there is still potential for dependence with prolonged use 5
Elderly Considerations: Lower doses are mandatory in elderly patients due to increased sensitivity to adverse effects and altered pharmacokinetics 2, 3
Zolpidem remains an effective option for treating insomnia when used at appropriate doses and durations, with efficacy comparable to benzodiazepines but with a generally more favorable side effect profile 5.