Should I discontinue (stop) zaleplon and switch to Ambien (zolpidem) for this patient?

Should You Discontinue Zaleplon and Switch to Zolpidem (Ambien)?

No, you should not routinely switch from zaleplon to zolpidem (Ambien) without a specific clinical indication, as both are Z-drugs with similar risks in older adults, and the American Academy of Sleep Medicine recommends zolpidem primarily when sleep maintenance (not just sleep onset) is the problem. 1

Key Decision Points

Determine the Type of Insomnia

The choice between these medications depends entirely on whether your patient has sleep onset insomnia alone versus sleep maintenance insomnia:

• Zaleplon is specifically indicated for sleep onset insomnia (difficulty falling asleep) due to its ultra-short half-life of approximately 1 hour 1
• Zolpidem is indicated for both sleep onset AND sleep maintenance insomnia (difficulty staying asleep) with a longer half-life of 2.4 hours 1

If your patient only has difficulty falling asleep and sleeps well once asleep, zaleplon is the more appropriate choice and should NOT be switched. 1 Switching to zolpidem would expose the patient to unnecessary longer-acting effects without additional benefit.

If your patient has difficulty both falling asleep AND staying asleep, then zolpidem would be the superior choice. 1 The American Academy of Sleep Medicine specifically recommends zolpidem over zaleplon for most insomnia cases because it addresses both components. 1

Critical Safety Considerations in Older Adults

Both Medications Carry Significant Risks

Both zaleplon and zolpidem are Z-drugs that act on the benzodiazepine GABA receptor complex and carry similar serious risks in older adults, including:

• Cognitive impairment 2
• Falls and fractures 2, 3
• Complex sleep behaviors (sleep-walking, sleep-driving) 4
• Reduced mobility and functional decline 2

In longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures compared to no treatment or melatonin agonists in older adults. 3 This risk applies to both zaleplon and zolpidem.

Age-Specific Dosing Requirements

For elderly patients, the recommended dose is 5 mg for zaleplon 4 and 5 mg for zolpidem immediate-release formulations 1 to decrease the possibility of side effects and account for slower drug metabolism. 4

Discontinuation Considerations

Zaleplon Has Minimal Withdrawal Risk

If you decide to discontinue zaleplon, you can do so abruptly without tapering:

• The American Academy of Sleep Medicine provides robust evidence that zaleplon causes no significant withdrawal symptoms on validated withdrawal questionnaires 5
• Polysomnography studies showed no evidence of withdrawal upon discontinuation 5
• Any discontinuation-related changes were "small in absolute magnitude and of doubtful clinical significance" 5
• Abrupt discontinuation is safe and appropriate for zaleplon at standard therapeutic doses (5-10 mg) 5

Common pitfall to avoid: Do not apply benzodiazepine withdrawal protocols to zaleplon discontinuation, as this represents unnecessary over-treatment. 5

Zolpidem Has More Withdrawal Concerns

Zolpidem carries greater risk of rebound insomnia and withdrawal symptoms compared to zaleplon:

• Sleep onset latency was significantly increased on the first night after stopping zolpidem (13.0 minutes increase) 6
• Studies showed indication of significant rebound insomnia for some patients after zolpidem discontinuation 7
• Withdrawal seizures have been reported with zolpidem, particularly at higher doses 6

Alternative Approach: Consider Deprescribing Entirely

Current consensus guidelines advise use of Z-drugs (including both zaleplon and zolpidem) solely on a short-term basis (typically 2-4 weeks). 2, 1

Rather than switching between Z-drugs, consider:

• Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment or in combination with pharmacotherapy 1, 8
• Psychological interventions including problem-solving, interpersonal therapy, or supportive psychotherapy 2
• Integrative strategies including massage, aromatherapy, music therapy, or multisensory stimulation 2

If pharmacological treatment remains necessary after failed non-pharmacological approaches, and sleep maintenance is the primary issue, consider:

• Suvorexant (orexin receptor antagonist) for sleep maintenance insomnia 8
• Low-dose doxepin (3-6 mg) as an alternative second-line agent 8

Bottom Line Algorithm

1. Assess insomnia type: Sleep onset only vs. sleep maintenance component
2. If sleep onset only: Keep zaleplon (no reason to switch)
3. If sleep maintenance problem: Switch to zolpidem is reasonable 1
4. If on therapy >2-4 weeks: Strongly consider deprescribing entirely and implementing CBT-I 2, 1
5. If discontinuing zaleplon: Abrupt discontinuation is safe 5
6. If elderly patient: Use 5 mg doses only 1, 4