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The older sedative-hypnotics that have a prolonged half-life increase the risk for next-day sedation and daytime psychomotor impairment and pose an increased risk for abuse and dependence.
Other complications of benzodiazepine use include tolerance, withdrawal, abuse, and rebound insomnia.
Sedative-hypnotics include nonbenzodiazepine receptor agonists (zaleplon, zolpidem, eszopiclone); short-acting benzodiazepine receptor agonists (triazolam); intermediate-acting benzodiazepine receptor agonists (estazolam, temazepam); and selective melatonin agonists (ramelteon).
Both eszopiclone and sustained-release zolpidem are effective for both sleep-onset and sleep-maintenance insomnia, with a reduced abuse potential and long-term efficacy of up to 6 months as compared with nonselective benzodiazepine receptor agonists.
Stimulation of the MT1 receptor in the suprachiasmatic nucleus (SCN) inhibits neuronal firing (reduces alerting effect of the SCN), and stimulation of the MT2 receptor in the SCN affects the circadian rhythm, causing a phase advance (earlier sleep time). The orexin neuropeptide signaling system is a central promoter of wakefulness.
Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R by suvorexant is thought to suppress wake drive.
It is a good first choice for treatment of sleep-onset insomnia and produces no significant residual sedation in the morning.
A sedative-hypnotic of the pyrazolopyrimidine class, zaleplon has a rapid onset of action and an ultra-short duration of action, making it a good choice for treatment of sleep-onset insomnia.
A second dose can be used during the middle of the night without residual sedation in the morning (this is believed to be an advantage of this hypnotic over others).
It is indicated for insomnia to decrease sleep latency and improve sleep maintenance. The starting dose is 1 mg immediately before bedtime, with at least 7-8 h remaining before the planned time of awakening.
The dose may be increased if clinically warranted to 2-3 mg HS in nonelderly adults, and 2 mg in elderly or debilitated patients.