The Pharmaceutical Journal
Vol 272 No 7297 p535
1 May 2004

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Lack of distinction between “z” drugs in insomnia

Treatment of insomnia should be driven by the cost of treatment because of a lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone and shorter-acting benzodiazepines.

The recommendation to prescribe the drug with the lowest price comes from the National Institute for Clinical Excellence, which published recommendations on use of the “z” drugs this week.

The guidance adds that non-pharmacological measures should be considered before hypnotic drug therapy is used and, as with other hypnotics, that the “z” drugs be prescribed for short periods only, in accordance with their licences.

NICE also advises that switching between these hypnotics should only occur if a patient experiences adverse effects considered to be directly related to a specific agent. These are also the only circumstances in which more expensive drugs are recommended, according to the guidance.

Patients who have not responded to one of these hypnotics should not be prescribed any of the others, the institute says.

David Taylor, chief pharmacist at the South London and Maudsley NHS Trust, commented to The Journal that there are differences between the “z” drugs and benzodiazepines in terms of pharmacology.

The “z” drugs have an abrupt onset and are shorter acting. Despite previous advice to limit the use of hypnotics, Dr Taylor believes they are still too readily prescribed and sleep hygiene methods are often not explored fully before resorting to drugs.

The guidance comments that pharmacists can deliver advice and education on non-pharmacological measures to manage insomnia. However, it adds that access to many of these therapies, such as cognitive behavioural therapy, is restricted through a combination of lack of trained therapists, costs and a poor understanding of available options.

The guidance points out that up to 40 per cent of people with insomnia self-medicate with non-prescription hypnotics, such as sedative antihistamines, available from pharmacies without prescription.

NICE this week also issued guidelines on Caesarean section and on procedures to treat heavy menstrual bleeding.