What is the recommended treatment protocol for insomnia using temazepam?

Temazepam for Insomnia Treatment

Temazepam should be initiated at 15 mg taken 30 minutes before bedtime for most adults with chronic insomnia, as this dose increases total sleep time by approximately 99 minutes compared to placebo with minimal adverse effects. 1

Initial Treatment Approach

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment before considering temazepam or any pharmacotherapy. 2 The American Academy of Sleep Medicine designates behavioral interventions—including stimulus control therapy, relaxation therapy, or multicomponent CBT-I—as standard initial treatment for chronic insomnia. 2

When pharmacotherapy becomes necessary, it should be supplemented with behavioral and cognitive therapies whenever possible. 2

Temazepam Dosing Protocol

Starting Dose

• Begin with 15 mg taken 30 minutes before bedtime for most adults with primary insomnia. 1, 3
• This dose improves both sleep onset latency and sleep maintenance, making it appropriate for mixed insomnia presentations. 1
• The 15 mg dose shows no notable increase in adverse effects versus placebo and minimal daytime impairment. 2, 1

Dose Adjustments

• For geriatric or debilitated patients, start with 7.5 mg to minimize risk of falls and cognitive impairment. 3
• If 15 mg is insufficient, increase to 20-30 mg based on response. 1, 3
• The 30 mg dose increases total sleep time by 53-55 minutes and reduces awakenings by 1.0-1.24 per night compared to placebo. 1

Important Pharmacokinetic Considerations

• Peak plasma concentrations occur 1.2-1.6 hours after dosing (mean 1.5 hours). 3
• The elimination half-life is 10-15 hours, allowing once-nightly dosing without significant accumulation. 3, 4
• Temazepam has a relatively longer half-life than zaleplon or zolpidem, making it more effective for sleep maintenance problems. 2

Duration of Treatment

Temazepam is FDA-approved for short-term use only (7-10 days). 3 However, clinical practice often extends beyond this:

• Prescriptions should indicate short-term use (7-10 days) for patients with acute insomnia. 3
• For chronic insomnia, regular follow-up every few weeks is required to assess effectiveness, side effects, and ongoing need. 2
• Use the lowest effective maintenance dose and attempt tapering when conditions allow. 2
• Studies show no tolerance development with nightly use for at least 2 weeks. 3

Adverse Effects by Dose

15 mg dose:

• No notable increase in adverse effects versus placebo. 2, 1
• Minimal daytime impairment on cognitive or motor performance. 2

20 mg dose:

• Modest increases in headache, blurred vision, depression, and confusion, though overall frequency remains low. 1

30 mg dose:

• Higher incidence of drowsiness, lethargy, and vertigo. 2, 1
• Potential daytime impairment on psychomotor tests (Choice Reaction Time Test, Critical Flicker Fusion Test). 2
• Use 30 mg only when lower doses are insufficient and benefits clearly outweigh risks. 2

Patient Selection Factors

When choosing temazepam within the benzodiazepine receptor agonist class, consider: 2

• Symptom pattern: Temazepam's intermediate half-life makes it suitable for both sleep onset and maintenance problems. 2, 1
• Past treatment responses: If shorter-acting agents (zaleplon, zolpidem) failed to maintain sleep, temazepam is appropriate. 2
• Age: Lower doses (7.5 mg) for elderly patients due to fall risk. 3
• Comorbid conditions: Screen for sleep apnea, substance use disorders, and respiratory conditions. 2
• Cost and patient preference: No specific agent within the BzRA class is superior in general. 2

Critical Monitoring Requirements

• Provide patient education regarding treatment goals, safety concerns, potential side effects, drug interactions, risk of dosage escalation, and rebound insomnia. 2
• Follow patients every few weeks initially to assess effectiveness and adverse effects. 2
• Attempt medication tapering when sleep improves or after 2-4 weeks of stable use. 2
• Combining temazepam with CBT-I reduces medication requirements and adverse effects while maintaining efficacy. 5

Common Pitfalls to Avoid

• Do not use temazepam as monotherapy without addressing behavioral factors—this reduces long-term success. 2
• Avoid starting at 30 mg unless lower doses have failed, as this increases adverse effects without proportional benefit in most patients. 2, 1
• Do not prescribe indefinitely without reassessment—chronic use requires regular evaluation for continued need. 2
• Screen for substance use disorders—patients with this history may be better candidates for ramelteon. 2