Can I switch a patient taking zopiclone (eszopiclone) 5mg 3 times a week for insomnia to Daveco, considering they have not tried Cognitive Behavioral Therapy for Insomnia (CBT-I)?

Switching from Zopiclone to Dayvigo: Prioritize CBT-I First

Before switching your patient from zopiclone to Dayvigo (lemborexant/suvorexant), you should first refer the patient for Cognitive Behavioral Therapy for Insomnia (CBT-I), as this is the recommended first-line treatment for chronic insomnia. 1, 2

Treatment Algorithm for Insomnia Management

Step 1: Implement CBT-I

• CBT-I is strongly recommended as the initial treatment for chronic insomnia by the American College of Physicians (strong recommendation, moderate-quality evidence) 1
• The patient has not tried CBT-I, which should be attempted before considering medication switches
• CBT-I has superior long-term effectiveness compared to medications with more durable effects and no risk of tolerance or adverse effects 3, 4

Step 2: Components of Effective CBT-I

The most effective CBT-I components include:

• Cognitive restructuring
• Stimulus control therapy
• Sleep restriction therapy
• Third-wave components 5

Step 3: Medication Management During CBT-I

• Continue zopiclone at current dosage (5mg, 2-3 times weekly) while initiating CBT-I
• Plan for gradual tapering of zopiclone as CBT-I progresses
• CBT-I should be extended throughout drug tapering to prevent relapse 6

Step 4: Consider Medication Switch Only If CBT-I Is Unsuccessful

If CBT-I alone is unsuccessful after an adequate trial (4-6 weeks):

• Use shared decision-making to discuss benefits, harms, and costs of medications 1
• Consider switching to Dayvigo (suvorexant/lemborexant) if indicated for sleep maintenance insomnia 2
• Suvorexant has moderate-quality evidence showing improved treatment response and sleep outcomes 1

Important Clinical Considerations

Medication Selection Principles

• Pharmacological treatment should be accompanied by patient education about:
  • Treatment goals and expectations
  • Safety concerns
  • Potential side effects and drug interactions
  • Rebound insomnia potential 1

Monitoring and Follow-up

• Schedule follow-up within 7-10 days of any treatment change
• Use standardized measures like the Insomnia Severity Index to track progress
• Employ the lowest effective maintenance dosage and taper when conditions allow 1, 2

Pitfalls to Avoid

1. Don't skip CBT-I: Relying solely on medication switching without trying CBT-I first contradicts evidence-based guidelines
2. Don't use sleep hygiene alone: Sleep hygiene education is necessary but insufficient as a standalone treatment 6
3. Avoid abrupt discontinuation: Gradual tapering of zopiclone is necessary to prevent withdrawal symptoms 2
4. Don't overlook intermittent dosing: Long-term administration may be nightly, intermittent, or as needed 1

Evidence Quality Assessment

The recommendation to try CBT-I before switching medications is supported by high-quality evidence from multiple guidelines. The American College of Physicians provides a strong recommendation with moderate-quality evidence for CBT-I as first-line treatment 1. Recent systematic reviews and meta-analyses further support the superior long-term effectiveness of CBT-I compared to pharmacological interventions 3, 5.