Increase Lunesta to 3 mg at Bedtime
If Lunesta 2 mg is not providing adequate sleep improvement after 1–2 weeks, increase the dose to 3 mg immediately before bedtime. 1
FDA-Approved Dosing Algorithm
The FDA label specifies that dosing can be raised from 2 mg to 3 mg if clinically indicated, with the total dose not to exceed 3 mg once daily. 1
The 3 mg dose produces substantially greater efficacy than 2 mg: it increases total sleep time by 57 minutes versus placebo (compared to 28 minutes with 2 mg) and reduces sleep latency by 25 minutes (exceeding the clinical significance threshold). 2, 3
Take the 3 mg dose within 30 minutes of bedtime with at least 7 hours remaining before planned awakening to minimize next-day impairment. 1
Important Safety Considerations
The higher 3 mg dose increases the risk of next-day impairment of driving and activities requiring full alertness due to elevated morning blood levels; counsel patients to avoid driving or operating machinery until they know how the medication affects them. 1
Common adverse effects at 3 mg include unpleasant/metallic taste (26–34%), somnolence (8.8–9.1%), dry mouth (6.6%), and dizziness (9.8%), though these are generally well tolerated. 3, 4, 5
Monitor for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) and discontinue immediately if they occur. 2
Dosing Exceptions
For elderly patients (≥65 years), the maximum dose is 2 mg—do not increase to 3 mg due to heightened sensitivity and fall risk. 1
For patients with severe hepatic impairment or taking potent CYP3A4 inhibitors, the maximum dose is 2 mg—do not increase to 3 mg. 1
Concurrent Behavioral Therapy
- Always combine eszopiclone with Cognitive Behavioral Therapy for Insomnia (CBT-I), as pharmacotherapy should supplement—not replace—behavioral interventions that provide superior long-term outcomes. 2, 6
Long-Term Use Profile
Unlike other hypnotics, eszopiclone has no short-term usage restriction and is approved for long-term treatment, with clinical trials demonstrating efficacy and safety for up to 6–12 months without tolerance or rebound insomnia upon discontinuation. 7, 8, 9, 10
After 8 weeks of eszopiclone treatment, no evidence of rebound insomnia was observed upon discontinuation in clinical trials. 7