What is the starting dose of temazepam (a benzodiazepine) for an adult patient with insomnia?

Starting Dose of Temazepam for Adult Insomnia

The recommended starting dose of temazepam for most adults with insomnia is 15 mg taken before bedtime, though 7.5 mg may be sufficient for some patients and should be the initial dose for elderly or debilitated patients. 1

Dosing Algorithm by Patient Population

Standard Adult Patients

• Start with 15 mg at bedtime as the recommended usual adult dose for insomnia 1
• This dose increases total sleep time by 64.4 minutes (moderate-quality evidence) and improves sleep efficiency by 13.3% on polysomnography 2
• The 15 mg dose shows no notable increase in adverse effects versus placebo, with no significant daytime impairment 2

Patients Who May Require Lower Initial Dosing (7.5 mg)

• Elderly patients should be initiated at 7.5 mg until individual responses are determined 1
• Debilitated patients should start at 7.5 mg 1
• Patients with transient insomnia may find 7.5 mg sufficient to improve sleep latency 1
• The 7.5 mg dose has been shown effective in elderly insomniacs, producing significant improvement in total wake time (100 vs. 145 minutes at baseline) with minimal adverse effects and no rebound insomnia upon withdrawal 3

When to Consider Higher Dosing (30 mg)

• Escalate to 30 mg only if 15 mg provides inadequate relief after an adequate trial 2
• The 30 mg dose reduces sleep latency by 40-45 minutes compared to placebo and increases total sleep time by 53-78 minutes 2
• However, 30 mg is associated with increased incidence of drowsiness, lethargy, vertigo, and daytime cognitive impairment compared to lower doses 2
• Do not increase to 30 mg if the patient experiences drowsiness, fatigue, or cognitive impairment at 15 mg 2

Critical Pharmacokinetic Considerations

Temazepam's absorption profile is slower than other benzodiazepines, reaching peak plasma concentrations within 3 hours after oral ingestion with a mean half-life of 10-15 hours 4. This slower absorption means:

• Temazepam may be less effective for sleep onset latency compared to sleep maintenance 4
• The medication should be taken on an empty stomach to maximize effectiveness 5
• It is particularly suited for patients with sleep maintenance insomnia rather than purely sleep-onset insomnia 5

Safety Warnings and Contraindications

Dose Adjustments Required

• Mandatory 50% dose reduction in elderly, debilitated patients, or those with hepatic impairment 5
• Avoid combining with alcohol, other CNS depressants, or during sleep restriction 5

Discontinuation Protocol

• Use gradual taper to discontinue or reduce dosage to minimize withdrawal reactions 1
• If withdrawal reactions develop, pause the taper or increase dosage to the previous level, then decrease more slowly 1
• Abrupt discontinuation can produce withdrawal symptoms including rebound insomnia 5

Long-Term Risk Considerations

• All benzodiazepine receptor agonists carry FDA warnings regarding complex sleep behaviors, daytime memory impairment, and potential association with dementia in observational studies 5
• Benzodiazepines are associated with dementia risk in observational studies, with greatest effect for higher-dose hypnotics 2
• The American Academy of Sleep Medicine rates all benzodiazepine recommendations as "WEAK" strength, indicating many patients might reasonably choose alternative treatments 2

Common Pitfalls to Avoid

• Do not start at 30 mg even in patients with severe insomnia—titration from lower doses is essential for safety 1
• Do not assume temazepam will effectively reduce sleep onset latency—the evidence is inconsistent for this parameter, particularly at 15 mg 6
• Do not prescribe for long-term continuous use without reassessment—hypnotic drugs should be adjunctive therapy for short-term periods with subsequent intermittent use as needed 3
• Do not overlook cognitive behavioral therapy for insomnia (CBT-I)—it should be considered first-line treatment before or alongside pharmacotherapy due to sustained benefits without tolerance or adverse effects 5