Can Zopiclone (eszopiclone) exacerbate sleep walking in patients with a history of somnambulism?

Zopiclone and Sleep Walking: Risk Assessment and Management

Zopiclone can exacerbate sleepwalking in patients with a history of somnambulism and should be avoided in these patients. 1, 2

Risk of Zopiclone and Sleep Walking

• Zopiclone (eszopiclone) belongs to the class of non-benzodiazepine hypnotics that act on GABA-A receptors and can trigger complex sleep behaviors including sleepwalking 3

• Case reports have documented sleepwalking episodes specifically associated with zolpidem (a similar non-benzodiazepine hypnotic), particularly in patients with a previous history of somnambulism 1, 2

• The FDA warns that non-benzodiazepine hypnotics like zopiclone/eszopiclone can cause complex sleep behaviors including "sleep-driving" and other activities while not fully awake, often with no memory of the event 4

• Patients with a history of brain injury may be more susceptible to this side effect, but it can occur even in patients without prior history of sleepwalking 1

Clinical Implications

• The FDA drug label for eszopiclone (Lunesta) specifically warns about complex sleep behaviors: "There have been reports of people getting out of bed after taking a sedative-hypnotic and driving their cars while not fully awake, often with no memory of the event" 4

• Other complex behaviors reported include "preparing and eating food, making phone calls, or having sex" in patients who are not fully awake after taking sedative-hypnotics 4

• These behaviors are more likely to occur when zopiclone is taken with alcohol or other central nervous system depressants 4

• Patients with a history of somnambulism are at higher risk for experiencing medication-induced sleepwalking episodes 2

Management Recommendations

• For patients with a history of sleepwalking, alternative treatments for insomnia should be considered: 5

  1. First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) - includes stimulus control, sleep restriction, and relaxation techniques 5

  2. Alternative medications if pharmacological treatment is necessary:

     • Ramelteon (a melatonin receptor agonist) which has not been associated with complex sleep behaviors 5
     • Low-dose sedating antidepressants such as trazodone, which may have a lower risk of triggering sleepwalking 5

• If a patient reports sleepwalking while taking zopiclone, the medication should be discontinued immediately 1, 2

• Ensure proper sleep environment safety measures for all patients prescribed hypnotics, especially those with any history of parasomnias 5

Important Precautions

• Zopiclone should be taken immediately before bedtime and only when patients can dedicate 8 hours to sleep 4

• Patients should be advised not to combine zopiclone with alcohol or other sedating medications as this increases the risk of complex sleep behaviors 4

• Patients with a history of depression, mental illness, suicidal thoughts, drug or alcohol abuse, or liver disease require special caution when considering hypnotic medications 4

• The FDA recommends that patients experiencing any episode of complex sleep behavior while taking a sedative-hypnotic should report it to their doctor immediately 4

• Elderly patients or those with hepatic impairment should receive reduced dosing due to increased half-life and drug exposure 4, 3

In conclusion, the evidence indicates that zopiclone can trigger or exacerbate sleepwalking, particularly in patients with a history of somnambulism. For these patients, alternative insomnia treatments should be prioritized to avoid potentially dangerous complex sleep behaviors.