What is the recommended taper schedule for zopiclone (eszopiclone) when switching to Dayvigo (lemborexant) in a patient taking 5mg of zopiclone at bedtime (HS) for sleep?

Zopiclone Taper Schedule When Switching to Dayvigo

For a 68-year-old patient on long-term zopiclone 5mg, taper the zopiclone over 4-8 weeks using 25% dose reductions every 1-2 weeks while initiating Dayvigo concurrently, as this gradual approach minimizes withdrawal symptoms including rebound insomnia, anxiety, and potential seizures. 1

Recommended Tapering Protocol

Week-by-Week Schedule

• Weeks 1-2: Reduce zopiclone to 3.75mg (25% reduction from 5mg) while starting Dayvigo at the prescribed dose 1
• Weeks 3-4: Reduce zopiclone to 2.5-3mg (approximately 25% of current dose) 1
• Weeks 5-6: Reduce zopiclone to 1.25-2mg 1
• Weeks 7-8: Discontinue zopiclone completely, extending the interval between doses before final discontinuation 1

Important: Each reduction should be 25% of the current dose, not the original dose, to prevent disproportionately large final reductions that increase withdrawal risk 1

For Patients on Long-Term Use (Years)

• Consider extending the taper to 10% reductions per month rather than the faster schedule above, as this patient has been on zopiclone for years 1
• The total taper duration may need to be 6-12 months minimum for optimal tolerability 1
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule 1

Critical Safety Considerations

Why Gradual Tapering is Essential

• Abrupt discontinuation of zopiclone can cause seizures and death, making gradual tapering absolutely necessary 1
• Benzodiazepine receptor agonists like zopiclone require cautious downward dosage adjustment, particularly in elderly patients (this patient is 68 years old) 1
• Withdrawal symptoms include anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, confusion, and seizures 1

Age-Specific Concerns

• Elderly patients face particular risks including cognitive impairment, reduced mobility, falls, fractures, and loss of functional independence 1
• Use lower doses and more gradual tapers in patients over 65 years 1
• Long-acting agents pose concerns for sedation and fall risk in this age group 1

Monitoring Requirements

Follow-Up Schedule

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for withdrawal symptoms at each visit 1
• Screen for depression, anxiety, and substance use disorders that may emerge during tapering 1
• Assess for suicidal ideation 1

When to Pause or Slow the Taper

• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
• If withdrawal symptoms become intolerable, hold at the current dose until symptoms stabilize before proceeding 1
• The goal is durability of the taper, not speed 1

Adjunctive Support Strategies

Non-Pharmacological Interventions

• Integrate cognitive behavioral therapy (CBT) during the taper, as this significantly increases success rates 1
• Provide sleep hygiene education 1
• Consider mindfulness and relaxation techniques 1
• Encourage exercise and fitness training 1

Pharmacological Adjuncts for Withdrawal Symptoms

• For insomnia breakthrough: Trazodone can be used for short-term management 1
• For anxiety: Consider gabapentin starting at 100-300mg at bedtime or three times daily, titrating by 100-300mg every 1-7 days as tolerated 1
• For muscle aches: NSAIDs or acetaminophen 1
• Carbamazepine or pregabalin may help mitigate withdrawal symptoms, though evidence is limited 1

Common Pitfalls to Avoid

Critical Errors

• Never taper too quickly - research shows that even 10% reductions every 3 days resulted in only 24% of patients successfully completing withdrawal 1
• Never abandon the patient even if tapering is unsuccessful; maintain the therapeutic relationship and consider maintenance therapy 1
• Never make equal dose reductions throughout the taper - reduce by percentage of current dose 1

Special Circumstances Requiring Specialist Referral

Refer immediately if the patient has: 1

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Alternative Approach: Direct Substitution Method

• One study found that immediate substitution (abuttal method) was the best method when switching from benzodiazepines to zopiclone, associated with better sleep and increased alertness 2
• However, this approach was studied for switching to zopiclone, not from it, and given the patient's age and years of use, the gradual taper approach above is safer 1

Realistic Expectations

• Patient education about zopiclone risks and benefits of tapering improves outcomes and engagement 1
• The taper will likely take 6-12 months minimum, possibly longer 1
• Success is defined as making progress, not speed of completion 1
• Once the smallest available dose is reached, extend the interval between doses before complete discontinuation 1