What is the recommended taper schedule for Lunestra (eszopiclone)?

Lunesta (Eszopiclone) Tapering Schedule

For Lunesta (eszopiclone), a gradual tapering schedule is recommended with dose reductions of 5-10% of the original dose every 1-2 weeks to minimize withdrawal symptoms and rebound insomnia. 1

Recommended Tapering Protocol for Lunesta

Initial Assessment

• Evaluate current dose and duration of use
• Assess for risk factors that may complicate tapering:
  • Advanced age
  • Liver impairment
  • History of seizures
  • Concurrent substance use

Standard Tapering Schedule

1. For patients on 3 mg dose:

   • Reduce to 2 mg for 1-2 weeks
   • Then reduce to 1 mg for 1-2 weeks
   • Then discontinue

2. For patients on 2 mg dose:

   • Reduce to 1 mg for 1-2 weeks
   • Then discontinue

3. For patients on 1 mg dose:

   • Consider using a pill cutter to reduce to 0.5 mg for 1-2 weeks
   • Then discontinue

Modified Schedules for Special Populations

Elderly Patients (≥65 years)

• Use more gradual tapering (5% reduction every 2 weeks)
• Begin with lower doses (typically 1-2 mg)
• Monitor more closely for withdrawal symptoms 1

Patients with Hepatic Impairment

• Use more gradual tapering due to increased half-life (9 hours vs 6 hours in healthy adults) 2
• Consider 2.5-5% reductions every 2 weeks 1
• Monitor for signs of over-sedation

Monitoring During Tapering

Withdrawal Symptoms to Monitor

• Sleep disturbances (rebound insomnia)
• Anxiety and irritability
• Tremor
• Diaphoresis (excessive sweating)
• Agitation
• Headache
• Dizziness 1

Management of Withdrawal Symptoms

• If significant withdrawal symptoms occur, return to previous dose and slow the taper
• Consider non-pharmacological approaches:
  • Cognitive behavioral therapy for insomnia
  • Sleep hygiene practices
  • Stress management techniques 1

Adjunctive Medications for Symptom Management

• For anxiety/agitation: Hydroxyzine
• For insomnia: Trazodone (low dose)
• For pain: Scheduled acetaminophen (not exceeding 3000mg daily) 1

Important Considerations

Rebound Insomnia

• Studies have shown that discontinuation of eszopiclone may be followed by rebound insomnia, particularly with the 2 mg dose 2
• Slower tapering may help minimize this effect

Risk of Dependence

• Although formal assessment of dependence is limited, eszopiclone at higher doses (6-12 mg) has shown euphoric effects similar to diazepam in studies 2
• This underscores the importance of gradual tapering

Pharmacokinetic Considerations

• Eszopiclone has a mean elimination half-life of 6 hours in adults, increasing to about 9 hours in patients 65 years or older 2
• This longer half-life in elderly patients may affect the tapering schedule

Common Pitfalls to Avoid

1. Tapering too quickly - This increases risk of withdrawal symptoms and rebound insomnia
2. Not adjusting for special populations - Elderly patients and those with hepatic impairment need more gradual tapering
3. Overlooking concurrent medications - Interactions may affect metabolism of eszopiclone
4. Discontinuing without a plan for managing insomnia - Have alternative strategies ready

By following this structured tapering approach, withdrawal symptoms can be minimized while successfully discontinuing Lunesta. The key is gradual reduction with careful monitoring for withdrawal symptoms, adjusting the pace of tapering as needed.