Temazepam for Occasional Insomnia in Middle-Aged Adults
Temazepam 15 mg at bedtime is an appropriate short-term hypnotic for a middle-aged adult without sleep apnea, dementia, or fall risk who needs occasional insomnia relief, but only after initiating Cognitive Behavioral Therapy for Insomnia (CBT-I) and limiting use to 7–10 days as indicated by FDA labeling. 1
Evidence-Based Rationale for Temazepam
The American Academy of Sleep Medicine recommends temazepam 15 mg for both sleep-onset and sleep-maintenance insomnia, citing moderate-quality evidence of clinically meaningful reductions in sleep-onset latency and improvements in total sleep time. 2
Temazepam significantly increases total sleep time by approximately 26–32 minutes compared with placebo and reduces nocturnal awakenings, making it effective for the full spectrum of insomnia symptoms. 3, 2
Temazepam is FDA-approved specifically for the short-term treatment of insomnia (generally 7 to 10 days), with clinical trials supporting efficacy over 2-week periods. 1
Temazepam has an intermediate half-life (10–15 hours) and reaches peak plasma concentrations within 3 hours, providing sustained sleep maintenance without the prolonged daytime sedation associated with long-acting benzodiazepines or the early-morning awakening seen with ultra-short agents. 4, 5
Mandatory First-Line Behavioral Intervention
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated before or alongside temazepam, as it provides superior long-term efficacy with sustained benefits after medication discontinuation. 3, 2
CBT-I includes stimulus control (leaving bed when unable to sleep), sleep restriction (time in bed ≈ total sleep time + 30 min), relaxation techniques, and cognitive restructuring of maladaptive sleep beliefs, all of which can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books. 3, 2
Dosing and Administration Protocol
Initiate temazepam 15 mg taken approximately 30 minutes before bedtime when at least 7–8 hours remain available for sleep; this dose demonstrated efficacy in clinical trials without a significant increase in adverse events compared with placebo. 2, 1
Do not exceed a total daily dose of 30 mg, as higher doses raise the risk of next-day psychomotor and cognitive impairment without added benefit. 2, 6
Limit temazepam use to the shortest feasible period (≤ 4 weeks for acute insomnia, ideally 7–10 days), consistent with FDA labeling that hypnotics are intended for short-term therapy. 3, 2, 1
For occasional (non-nightly) use, temazepam can be taken intermittently as needed rather than continuously, which minimizes tolerance development and adverse effects while maintaining efficacy. 6, 5
Safety Monitoring Requirements
Reassess treatment effectiveness and safety after 1–2 weeks, focusing on sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and any signs of morning sedation, cognitive impairment, or behavioral changes. 2
Screen for complex sleep behaviors (e.g., sleep-driving, sleep-walking, sleep-eating) at each visit and discontinue temazepam immediately if such behaviors are identified, as these are potentially life-threatening adverse effects. 2
If insomnia persists beyond 7–10 days despite therapy, evaluate for underlying sleep disorders such as obstructive sleep apnea, restless-legs syndrome, periodic limb movement disorder, or circadian-rhythm abnormalities. 3, 2
Advantages Over Alternative Agents
Temazepam produces fewer residual daytime effects than long-acting benzodiazepines (e.g., flurazepam, nitrazepam) because it lacks long-acting metabolites and is metabolized more quickly. 4, 6
Temazepam has a lower propensity for rebound insomnia upon discontinuation compared with ultra-short-acting agents like triazolam, making it suitable for intermittent use. 7
In older studies, temazepam 7.5–30 mg demonstrated a low incidence of adverse effects (7.8% of complaints) with mild severity that decreased over time, and behavioral tolerance to side effects developed without significant daytime sedation or memory impairment. 8
Comparative Context with Newer Agents
The American College of Physicians notes insufficient evidence for benzodiazepine hypnotics overall, but temazepam remains one of the few benzodiazepines with FDA approval and moderate-quality evidence for insomnia. 3
Newer non-benzodiazepine hypnotics (eszopiclone, zolpidem) and orexin antagonists (suvorexant) have comparable or slightly superior efficacy for global outcomes, but temazepam remains a reasonable option when these agents are unavailable, contraindicated, or cost-prohibitive. 3
Comparative trials show similar efficacy between temazepam 20 mg and zolpidem 10 mg for sleep-onset latency and wake after sleep onset, though zolpidem increased total sleep time by 27 minutes more than temazepam in one trial. 3
Integration with Behavioral Therapy
Ensure CBT-I is incorporated alongside pharmacologic treatment; failure to do so diminishes durable therapeutic benefit and increases reliance on medication. 2
The addition of CBT-I to temazepam reduces the amount of medication used and the incidence of adverse effects, with comparable sleep improvements compared with medication alone. 8
Common Pitfalls to Avoid
Do not prescribe temazepam without first initiating CBT-I, as behavioral interventions provide more sustained effects than medication alone. 3, 2
Avoid continuous nightly use beyond 2 weeks without reassessment, as evidence for long-term safety is insufficient and tolerance may develop. 3, 1
Do not combine temazepam with other CNS depressants (e.g., alcohol, opioids, other benzodiazepines) without extreme caution, as this markedly increases the risk of respiratory depression, cognitive impairment, and falls. 3
Recognize that temazepam is contraindicated in patients with sleep apnea, severe respiratory insufficiency, or myasthenia gravis due to respiratory depression risk. 1