Practice Guidelines

Deprescribing Benzodiazepine Receptor Agonists for Insomnia in Adults


Key Points for Practice

• A slow taper of BZRAs is recommended in patients 18 to 64 years of age who use these most days of the week for more than four weeks.

• Patients 65 years and older taking a BZRA for any duration should be recommended to taper off slowly.

• A slow taper with a 25% dose reduction every two weeks and medication-free days at the end of the taper is suggested.

From the AFP Editors

Benzodiazepine receptor agonists (BZRAs), which include benzodiazepines and drugs such as zolpidem (Ambien), are often used to treat insomnia. Although they are beneficial for short-term improvement in sleep onset latency and duration, they also have associated harms, including problems with dependence. Evidence suggests that the benefits of BZRAs for insomnia wane after four weeks, whereas harms can continue, especially for older persons, including a greater risk of falls, motor vehicle collisions, problems with memory, and daytime sedation. A multidisciplinary group of clinicians as part of the Deprescribing Guidelines in the Elderly project has developed evidence-based guidelines focused on deprescribing long-term BZRAs in patients taking them for insomnia, with the goal of helping physicians and patients make appropriate decisions about BZRA use.

Deprescribing BZRAs has been proven successful in studies and is associated with only mild withdrawal symptoms (e.g., insomnia in the short term, anxiety, restlessness). Deprescribing options include abrupt discontinuation, tapering, cognitive behavior therapy (CBT) provided by trained personnel or via self-help, CBT and tapering combined, using lower dosages, using BZRAs as needed, or switching medications (e.g., melatonin). CBT combined with tapering improved BZRA cessation when compared with tapering alone. CBT for insomnia includes education regarding sleep, regulating stimulation, limiting sleep, sleep hygiene, and relaxation, and is associated with improved sleep and long-term benefits.

Tapering should be recommended to all patients taking BZRAs. Harms, waning effectiveness, rate and length of tapering, monitoring, and the possibility of withdrawal symptoms should be discussed. Based on low-quality evidence, patients 18 to 64 years of age who use BZRAs most

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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Dec 1, 2019

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