Management of Sleep-Maintenance Insomnia in a Patient on Temazepam
Switch from temazepam to a medication specifically effective for middle-of-the-night awakenings, such as low-dose doxepin 3–6 mg or suvorexant 10 mg, while simultaneously initiating Cognitive Behavioral Therapy for Insomnia (CBT-I).
Why Temazepam Is Failing This Patient
Temazepam's pharmacokinetic profile makes it poorly suited for sleep-maintenance insomnia—it reaches peak plasma concentrations 2–3 hours after ingestion and has a half-life of 10–15 hours, meaning therapeutic levels arrive too late to prevent middle-of-the-night awakenings and persist into the morning, causing residual sedation 1, 2.
The American Academy of Sleep Medicine recommends temazepam 15 mg for both sleep-onset and sleep-maintenance insomnia, but the evidence base shows temazepam primarily reduces total wake time and increases sleep duration rather than specifically targeting wake after sleep onset 3, 4.
Clinical trial data demonstrate that temazepam 30 mg administered in the middle of the night does not reduce latency to return to sleep and produces significant morning performance decrements 5–6.5 hours post-dose—exactly the problem this patient is experiencing 2.
First-Line Pharmacologic Recommendation
Low-dose doxepin 3 mg at bedtime is the preferred agent for sleep-maintenance insomnia, with moderate-quality evidence showing a 22–23 minute reduction in wake after sleep onset, improvements in sleep efficiency and total sleep time, minimal anticholinergic effects at hypnotic doses, and no abuse potential 3, 5.
If doxepin 3 mg is insufficient after 1–2 weeks, increase to 6 mg—this dose range maintains the favorable safety profile while providing additional efficacy for middle-of-the-night awakenings 3, 5.
Suvorexant 10 mg is an alternative orexin-receptor antagonist that reduces wake after sleep onset by 16–28 minutes through a completely different mechanism than benzodiazepine-type agents, with lower risk of cognitive and psychomotor impairment 3, 5.
Mandatory Concurrent Behavioral Therapy
The American Academy of Sleep Medicine and the American College of Physicians issue a strong recommendation that all adults with chronic insomnia receive CBT-I as initial treatment before or alongside any pharmacotherapy, because it provides superior long-term efficacy with sustained benefits after medication discontinuation 3, 5.
Core CBT-I components must include stimulus control (leave bed if unable to sleep within ~20 minutes), sleep restriction (limit time in bed to approximate actual sleep time), relaxation techniques, and cognitive restructuring of negative sleep beliefs—sleep hygiene education alone is insufficient 3, 5.
Temazepam Discontinuation Strategy
Taper temazepam gradually using a 25% dose reduction every 1–2 weeks to avoid acute withdrawal reactions including rebound insomnia, anxiety, and rarely seizures—abrupt discontinuation of benzodiazepines can precipitate life-threatening withdrawal 6.
Initiate the replacement agent (doxepin or suvorexant) at the start of the temazepam taper, not after completion, to maintain sleep continuity during the transition period 5.
Why NOT Continue or Increase Temazepam
Temazepam 30 mg has been associated with daytime impairment on cognitive tests and increased reports of drowsiness, lethargy, and vertigo compared to lower doses—escalating the dose will worsen morning sedation without addressing the core problem of middle-of-the-night awakenings 4.
The FDA warns that temazepam can cause complex sleep behaviors (sleep-driving, sleep-walking) and that the risk increases with doses exceeding the maximum recommended dose or when combined with alcohol and other CNS depressants 6.
Monitoring and Reassessment
Reassess sleep parameters after 1–2 weeks of the new agent: evaluate sleep-onset latency, total sleep time, number of nocturnal awakenings, time to return to sleep after awakening, daytime functioning, and adverse effects including morning sedation, cognitive impairment, falls, and complex sleep behaviors 3, 5.
If insomnia persists beyond 7–10 days despite appropriate treatment, evaluate for underlying sleep disorders such as obstructive sleep apnea, restless-legs syndrome, periodic limb movement disorder, or circadian rhythm disorders 3, 6.
Common Pitfalls to Avoid
Do not add a second hypnotic to temazepam—combining multiple sedating agents markedly increases the risk of respiratory depression, cognitive impairment, falls, fractures, and complex sleep behaviors 5.
Do not prescribe temazepam for middle-of-the-night dosing—its slow absorption and long half-life make it unsuitable for this indication, and clinical trials show no benefit for latency to return to sleep when given at 3.5 hours after bedtime 2.
Do not initiate or switch pharmacotherapy without concurrent CBT-I—this is the single biggest mistake in insomnia management, as behavioral therapy provides more durable benefits than medication alone 5.
Do not use over-the-counter antihistamines (diphenhydramine, doxylamine) as alternatives—the American Academy of Sleep Medicine explicitly recommends against these agents due to lack of efficacy data, strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation), and rapid tolerance development within 3–4 days 3, 5.