is double the recommended dose for older patients. Dalmane, with a half-lifeof between 50-100 hours, is not exactly afirst-line sleeping pill for the elderly,and, not surprisingly, it caused morenext-day cognitive impairment than Ambien CR.Bottom line: In the absence of therelevant comparative data, we’re left to our own anecdotal sense of whether AmbienCR actually poses clinical advantages.
Sonata seems to have completely dropped off everybody’s radar screen, which is too bad, because it helpspatients get to sleep and it causes nonext day grogginess, even when taken inthe middle of the night (Hindmarch I, etal.,
. 2001;16(2):159-167). It is not approved for sleepmaintenance.
Let’s face it: aside from a memorablecommercial, Lunesta has no advantagesover its competitors and has marked dis-advantages. Its half-life is long, at 6hours, meaning that it likely causesmore next-day impairment than its com-petitors. In its promotional material,Sepracor claims no next-day residual effectsin most patients. But if you dig into theactual data behind this claim, you’ll findthat they chose a very convenienttimepoint for their assessment-9.5 hours and12 hours (Lunesta package insert) – whereas the other nonbenzos assessedfor cognitive effects at 8 hours (see, for example, Ambien CR package insert).Like the foolish man looking for his car keys far from where he dropped them“because the light’s better here,” Sepracor opted to shed their research light far enoughaway from the time of ingestion toguarantee a good marketing line.In fact, the precursor of Lunesta,zopiclone, does cause next-day impair-ment and is associated with a risk of car accidents (Staner L et al.,
(Berlin) 2005;181(4):790-798). The nailin Lunesta’s coffin is that it causes anunpleasant taste in 20-40% of people who take it (Lunesta package insert),prompting some Sepracor reps to recom-mend that patients bite into a lemon whenthey wake up in the morning. Thanks, butI’ll order the waffles instead.If you don’t have anything compellingto say about your product, just keep fund-ing opinion leaders to write somethingabout it, no matter how irrelevant– even-tually, you’ll build up market share, if only through literature saturation alone.Thus, we have company-funded studiessuch as a recent one in which 410menopausal women with insomnia wererandomized to receive either Lunesta or placebo. And indeed, Lunesta, a sleepingpill, helped these women sleep better (Soares CN et al.,
2006;108:1402-1410). This is a contribu-tion to the medical literature…how?bottom line: Lunesta has the samehalf life as Restoril (temazepam), is 100times more expensive, and has resulted ina scourge of Luna moths fluttering aroundpeople’s ears while they are trying to sleep.
There are two good things to say about Rozerem: it has no abuse potential(really, none,
) and it has a differentmechanism of action from its competitors.Rather than acting by revving up GABA, itstimulates two subtypes of the melatoninreceptors in the brain’s suprachiasmaticnucleus (SCN): MT1 and MT2. Of the two,MT1 is most specific for sedation, andRozerem has a 15-fold greater affinity for MT1 than straight melatonin, a fact thatprobably accounts for why melatonin isonly mildly effective as a sleep aid (seethis meta-analysis of melatonin studies:Brzezinski A et al.,
Rev 2005;9:41-50).For some reason, Rozerem has theanecdotal reputation of having a one totwo week “lag time” before working, butthis is not true. In fact, a recent review of the Rozerem studies, written by twopharmacists who received no paymentsfrom Takeda, concluded that it improvessleep latency on nights one and two as well as any of the competing agents(Borja NL et al.,
2006;28:1540-1555). It has not been shown todecrease a standard measure of sleep, WASO (wake time after sleep onset), soit did not win the sleep maintenanceindication. According to experts I consulted,Rozerem doesn’t deliver the obvious“knock out punch” that the benzos and
Publisher and Editor-in-Chief:
Daniel J. Carlat, M.D.,
is assistant clinical professor of psychiatry at Tufts University School of Medicine andmaintains a private practice in Newburyport, Massachusetts. He graduated from the psychiatric residency at Massachusetts General Hospital in1995 and is founding editor of
The Practical Guide Series in Psychiatry
, published by Lippincott Williams & Wilkins.
Marcia L. Zuckerman, M.D.,
practices psychiatry at HRI/Arbour in Brookline, Massachusetts.
Dan Egli, Ph.D.,
private practice, Williamsport, Pennsylvania
Ivan Goldberg, M.D.,
creator, Depression Central Web Site, psychopharmacologist in private practice, New York City
Alan D. Lyman, M.D.,
child and adolescent psychiatrist in private practice, New York City
Robert L. Mick, M.D.,
medical director, DePaul Addiction Services, Rochester, New York
Michael Posternak, M.D.,
staff psychiatrist, Massachusetts General Hospital, BostonDr. Carlat, with editorial assistance by Dr. Zuckerman, is the author (unless other authorship is specified) of all articles and interviews for
The Carlat Psychiatry Report
. All editorial content is peer reviewed by the editorial board. Dr. Carlat, Dr. Egli, Dr. Goldberg, Dr. Lyman, Dr. Mick,Dr. Posternak, and Dr. Zuckerman have disclosed that they have no significant relationships with or financial interests in any commercial
companies pertaining to this educational activity.
Sleeping Pills, New and Old
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