Recommended Medications for Intermittent Sleep Aid

For patients requiring intermittent sleep aid rather than continuous therapy, as-needed zolpidem is the most appropriate medication option. 1

First-Line Options for Intermittent Sleep Aid

Zolpidem (as-needed): The evidence specifically supports zolpidem 10 mg as an effective intermittent sleep aid that can be used on an as-needed basis rather than nightly 1
- Reduces sleep onset latency by approximately 15 minutes compared to placebo 1
- Increases total sleep time by 48 minutes on nights when taken 1
- Improves global outcomes with 54% of patients reporting "much or very much improved" sleep (versus 24% with placebo) 1
Sublingual zolpidem: Particularly useful for middle-of-night awakenings 1
- Low-dose sublingual zolpidem (3.5 mg) reduces sleep latency after middle-of-night awakenings by 18 minutes 1
- Provides faster onset than oral formulations, making it suitable for as-needed use 2

Standard dosing: 10 mg for adults under 65 years 1
Reduced dosing: 5 mg for elderly patients or those with hepatic impairment 1, 3
Administration timing: Should be taken only when there are at least 7-8 hours available for sleep to avoid next-day impairment 3
Frequency: Can be used 3-5 times per week as needed rather than nightly 1

Sleep onset: Effectively reduces time to fall asleep 1
Sleep maintenance: Improves total sleep time on nights when taken 1
Global sleep quality: Patients report better overall sleep quality compared to placebo 1, 4
Minimal tolerance: Limited evidence of tolerance developing with intermittent use 5

Next-day impairment: Risk of residual sedation and psychomotor impairment the following day, especially at higher doses 3
- FDA has required lower recommended doses due to next-morning impairment risk 1
- Women may have higher plasma concentrations than men after 8 hours 6
Complex sleep behaviors: Rare but serious risk of sleep-related activities like sleepwalking, sleep-driving, and eating while not fully awake 3, 6
Falls and fractures: Associated with increased risk of falls, particularly in hospitalized and elderly patients 6
- Relative risk for hip fractures is 1.92 in patients taking zolpidem 6
Contraindications: Should be avoided in pregnancy (Category C), patients with severe respiratory depression, and those with sleep apnea 6

Eszopiclone: Another option for intermittent use, though less specifically studied for as-needed use 1, 3
- Effective for both sleep onset and maintenance insomnia 1
- No short-term usage restriction in labeling 1
Zaleplon: Very short-acting option (half-life approximately 1 hour) 1
- Particularly suitable for sleep onset difficulties 1
- Can be used when less than 4 hours remains for sleep 1
Ramelteon: Melatonin receptor agonist with no abuse potential (non-scheduled) 1
- Primarily effective for sleep onset insomnia 1
- May be preferred in patients with history of substance abuse 1

Start with lowest effective dose: Begin with 5 mg for women and elderly patients, 10 mg for other adults 1
Take on empty stomach: Administration on an empty stomach maximizes effectiveness 1
Avoid alcohol and other CNS depressants: Combination increases risk of adverse effects 1, 6
Limit to short-term use: Although intermittent use may extend the duration of therapy, regular reassessment is recommended 5

Assess for complex sleep behaviors: Patients should report any episodes of sleepwalking or other unusual nighttime activities 3, 6
Monitor for dependence: While risk is lower with intermittent use, monitor for increasing frequency of use 5
Evaluate next-day functioning: Patients should report any daytime impairment, particularly affecting driving or operating machinery 3