Tools for Practice Outils pour la pratique


#126 Z-drugs for sleep: Should we “Catch Some Z’s”?


CLINICAL QUESTION
QUESTION CLINIQUE
Are Z-drugs (zopiclone, zolpidem, and eszopiclone) safe and effective in insomnia?


BOTTOM LINE
RÉSULTAT FINAL
Z-drugs help people fall asleep faster (~13-22 minutes) and perhaps get ~5% more time sleeping while in bed. Z-drugs may increase the risk of mild infections (one in 43 patients) and have some inconsistent cognitive effects like reduced verbal memory or attention. 



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
Seven systematic reviews1-7 (with duplicate publications4-7), including 3-48 randomized controlled trials (RCTs) (96-10,926 patients). Some focused primarily on benzodiazepines (with Z-drugs secondarily considered).1,2 Compared to placebo,  Z-drugs significantly affected:  Falling asleep faster: ~13-22 minutes.3-5  
  • Total sleep time: Not statistically different3-5 except by patient diary, 32 minutes more.4,5  
  • Perceived sleep quality: No difference in two meta-analyses.1,3 Another showed “moderate” improvement (standard mean difference 0.48).4  
  • Time asleep while in bed: no difference3 or improved ~5%.4,5  
  • Limitations: Not all outcomes evaluated in all reviewsshort duration (example mean 34 days3), used multiple comparisons, funded by manufacturers or funding source not reported,5,7 and possible publication bias.1  
Adverse effects: 
  • Meta-analysis of 20 RCTs (367 patients, mean age 37) found no significant effects on speed of processing, working/verbal memory or attention nine hours after drug administration compared to “control” except for: 
    • Moderate” negative effects (effect sizes 0.42-0.56) on verbal memory (zopiclone and zolpidem) and attention (zolpidem).8 
  • Meta-analysis of 36 placebo-controlled RCTs (13,211 patients) found significantly increased infections (6.9% vs. 4.6%, number needed to harm 43 over 36 days). Most infections likely mild (example pharyngitis).9 
  • Z-drugs (and other sedative-hypnotics) have been associated with increased mortality in some,10,11 but not all,12,13 cohort studies. 
    • Numerous potential confounders (like Z-drug patients sicker) and causation unproven
Context: 
  • Compared to benzodiazepines, there is no difference in time to fall asleep,2,6 sleep quality1,6 or adverse events.1 Total sleep time may be better with benzodiazepines (23 minutes).2 
  • Guidelines recommend zopiclone for short-term (<7 consecutive nights) or long-term (<3 nights/week) as an adjunct to cognitive and behavioural therapies.14 


Latest Tools for Practice
Derniers outils pour la pratique

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

#364 Facing the Evidence in Acne, Part II: Oral Antibiotics

How effective are oral antibiotics in treating acne of at least mild-moderate severity?
Read Lire 0.25 credits available Crédits disponibles

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • Adrienne J Lindblad BSP ACPR PharmD
  • G. Michael Allan MD CCFP

1. Glass J, Lanctôt KL, Herrmann N, et al. BMJ. 2005 Nov 19; 331(7526):1169.

2. Holbrook AM, Crowther R, Lotter A, et al. CMAJ. 2000 Jan 25; 162(2):225-33.

3. Huedo-Medina TB, Kirsch I, Middlemass J, et al. BMJ. 2012 Dec 17; 345:e8343.

4. Buscemi N, Vandermeer B, Friesen C, et al. Evid Rep Technol Assess (Summ). 2005 Jun; (125):1-10.

5. Buscemi N, Vandermeer B, Friesen C, et al. J Gen Intern Med. 2007 Sep; 22(9):1335-50.

6. Dündar Y, Boland A, Strobl J, et al. Health Technol Assess. 2004 Jun; 8(24):iii-x, 1-125.

7. Dündar Y, Dodd S, Strobl J, et al. Hum Psychopharmacol. 2004 Jul; 19(5):305-22.

8. Stranks EK, Crowe SF. J Clin Exp Neuropsych. 2014 Sep; 36(7): 691-700.

9. Joya FL, Kripke DF, Loving RT, et al. J Clin Sleep Med. 2009; 5(4):377-83.

10. Weich S, Pearce HL, Croft P, et al. BMJ. 2014 Mar 19; 348:g1996.

11. Kripke DF, Langer RD, Kline LE. BMJ Open. 2012 Feb 27; 2(1):e000850.

12. Gisev N, Hartikainen S, Chen TF, et al. Can J Psychiatry. 2011 Jun; 56(6):377-81.

13. Jaussent I, Ancelin ML, Berr C, et al. BMC Med. 2013 Sep 26; 11:212.

14. Towards Optimized Practice. Adult Insomnia: Diagnosis to management. Available for download at: http://www.topalbertadoctors.org/download/439/insomnia_management_guideline.pdf. Accessed July 3, 2014.

Authors do not have any conflicts to disclose.