Lunesta (Eszopiclone) Dosing and Treatment Duration
For non-elderly adults (18-64 years), start with eszopiclone 2 mg immediately before bedtime, increasing to 3 mg if needed for improved efficacy; for elderly patients (≥65 years), start with 1 mg and increase to 2 mg maximum if necessary. 1, 2
Dosage by Age Group
Non-Elderly Adults (18-64 years)
- Starting dose: 2 mg immediately before bedtime 1, 2
- Maximum dose: 3 mg if 2 mg is insufficient for sleep onset or maintenance 1, 2
- The 3 mg dose demonstrates superior efficacy, reducing subjective sleep latency by approximately 25 minutes and increasing total sleep time by 57.1 minutes compared to placebo 3
Elderly Patients (≥65 years)
- Starting dose: 1 mg for sleep onset complaints 1, 2
- Maintenance dose: 2 mg maximum for sleep onset and/or maintenance 1, 2
- Three major trials specifically evaluated elderly patients and confirmed efficacy at these lower doses 3
Special Populations
- Severe hepatic impairment: Start with 1 mg, maximum 2 mg 1
- No dosage adjustment required for renal dysfunction 4
Treatment Duration
Eszopiclone is approved for long-term use without duration restrictions, distinguishing it from most other hypnotics. 2, 5, 6
- Studies up to 6 months demonstrated sustained efficacy without tolerance development 3, 2
- One trial extended to 12 months showed continued benefit with no evidence of tolerance 5, 6, 7
- The American Academy of Sleep Medicine recommends periodic reassessment for continued need, though no specific timeframe is mandated 1
Administration Guidelines
Timing and Food Interactions
- Take immediately before bedtime 1, 2
- Ensure 7-8 hours available for sleep before planned awakening 1
- Avoid taking with or immediately after high-fat meals, as this delays absorption and reduces efficacy 1
Critical Safety Warnings
- Absolutely avoid combining with alcohol or other CNS depressants 1
- Risk of complex sleep behaviors including sleepwalking, sleep-eating, and sleep-driving has been documented 1
- Next-day impairment is clinically significant with 3 mg doses, showing psychomotor and memory impairment up to 11.5 hours post-dose, even when patients subjectively feel unimpaired 2
Efficacy Profile by Dose
2 mg Dose
- Reduces objective sleep latency by 14.87 minutes (95% CI: -5.47 to -24.27 minutes) 3
- Increases total sleep time by 27.53 minutes, just below the 30-minute clinical significance threshold 3
- Quality of evidence rated as LOW due to imprecision and publication bias 3
3 mg Dose
- Reduces subjective sleep latency by 25 minutes (95% CI: -13.94 to -36.07 minutes), exceeding clinical significance 3
- Increases total sleep time by 57.1 minutes, substantially exceeding the 30-minute threshold 3
- Improves sleep efficiency by 5.61%, meeting clinical significance 3
- Quality of evidence rated as MODERATE to LOW depending on outcome measure 3
Discontinuation Strategy
Gradual discontinuation is recommended to minimize potential withdrawal symptoms, though rebound insomnia and serious withdrawal effects were not consistently observed in trials 1, 5, 6
- One study documented withdrawal symptoms (anxiety, abnormal dreams, hyperesthesia, nausea) following abrupt discontinuation of 2-3 mg doses 7
- No significant changes on Benzodiazepine Withdrawal Scale scores were observed in one 6-month trial 3
Common Pitfalls to Avoid
Do not assume patients recognize their impairment: The 3 mg dose causes objective psychomotor and memory impairment that patients do not subjectively perceive 2
Do not overlook the unpleasant taste side effect: This occurs in 17-26% of patients on 3 mg (versus 0.5-5.6% on placebo) and may affect adherence 3
Do not use standard adult doses in elderly patients: The elimination half-life increases from 6 hours to approximately 9 hours in patients ≥65 years, necessitating lower doses 7
Do not prescribe without counseling on sleep hygiene: Ensure patients understand the 7-8 hour sleep requirement and timing restrictions 1