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. 2026 Sep 18;123(19):515–521. doi: 10.3238/arztebl.m2026.0141

Recommendations on Switching or Deprescribing Hypnotic Medications for Insomnia

Göran Hajak 1, Ingo Fietze 2, Christoph Schöbel 3, Michael Saletu 4, Birgit Högl 5, Yaroslav Winter 6,✉; for the Insomnia Working Group of the German and Austrian Societies for Sleep Research and Sleep Medicine
PMCID: PMC13626306  PMID: 42535778

Summary

Background:

10–30% of the world’s population suffers from insomnia. One-quarter of those who take hypnotic medication become dependent on it. Given the wide variety of available drugs, switching them is complex. The existing recommendations do not cover all drug classes. There is a need for practical, evidencebased recommendations that take account of specific aspects of care both in Europe as a whole and regionally.

Methods:

This narrative review is based on publications from May 1953 to February 2026 that were retrieved by a search in six English- and German-language databases, including guidelines, meta-analyses, systematic reviews, randomized controlled trials, and observational studies. Following the literature review, new recommendations were developed in a consensus process (consensus conference followed by the Delphi method) to supplement the current insomnia guideline.

Results:

Treatment can be discontinued abruptly after short-term use (1–2 weeks) or if the drug in question does not produce withdrawal symptoms, e.g., daridorexant (an orexin receptor antagonist), melatonin, antihistamines, and phytotherapeutic drugs. Benzodiazepine receptor agonists, antidepressants, antipsychotics, and gabapentinoids should be tapered off gradually after medium- or long-term use (> 2 weeks), with a weekly dose reduction of 10–25%. Various gradual tapering methods can be used, depending on the drug, dose, duration of use, treatment regimen, and intended subsequent treatment. A l onger taper is advisable after use at high doses (≥ 2/3 of the maximum dose) or over the long term (≥ 1 year). Withdrawal symptoms from benzodiazepine receptor agonists can be alleviated with the overlapping administration of daridorexant or eszopiclone. Behavioral therapy is recommended as an accompanying nonpharmacological treatment (relative risk [RR]: 1.68; 95% confidence interval: [1.19; 2.39]).

Conclusion:

A drug-specific approach with evidence-based and practice-oriented protocols should be used when hypnotic medications are switched or discontinued.

Information on CME.

This article has been certified by the North Rhine Academy for Continuing Medical Education. The questions on this article may be found (in German) at http://daebl.de/RY95 (Deutsches Ärzteblatt’s CME portal). Their English translation may be found in the PDF version of this article. The closing date for entries is September 17, 2027.

Participation is possible at cme.aerzteblatt.de

Approximately 10–30% of the world’s population experience insomnia. About half of affected individuals are treated with medication. In Germany, 6.3% of the population takes hypnotic medications (e1). Of these, one-quarter become dependent on it (1, e2–e3). Given that most of these medications—with the exception of daridorexant and eszopiclone—are approved for a maximum treatment duration of four weeks, that long-term use of these drugs disrupts sleep physiology, and that cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line treatment, switching or deprescribing hypnotic medications is an issue of great clinical relevance. Unfortunately, these topics have not received adequate attention in national and European sleep medicine guidelines (2, 3). Similarly, the recommendations on switching or deprescribing treatments for insomnia published by experts groups from the United States (4) and Italy/France (5) in recent years do not take psychotherapeutic approaches and national peculiarities of German-speaking regions and other European countries, such as approval status and availability of specific medications, adequately into account.

Methods

The Insomnia Working Group of the German and Austrian Societies for Sleep Research and Sleep Medicine has established a task force dedicated to the topic of “deprescribing and switching hypnotic medications“. It brings together experts in the fields of sleep medicine, neurology, psychiatry, and internal medicine. The task force‘s goal is to supplement the national and European guidelines with evidence relating to the deprescribing and switching of treatments.

This narrative review is based on publications from May 1953 to February 2026 that were retrieved by a search in the PubMed, ScienceDirect, CINAHL, Embase, LIVIVO, and BASE databases for pertinent English- and German-language papers. Details on the literature search and consensus-building process are provided in the eBox and eFigure. We took country-specific aspects of Germany and Austria into account. For example, in Germany, daridorexant is the first representative of the class of dual orexin receptor antagonists (DORAs) and is approved for prescription with no restriction on treatment duration.

eBox. Methods.

We searched the PubMed, ScienceDirect, CINAHL, Embase, LIVIVO, and BASE databases for pertinent English- and German-language publications on the topic of “Switching and deprescribing hypnotic medications”. Studies from May 1953 to February 2026 were included in the search.

We used the search terms “switching AND insomnia“, “deprescribing AND insomnia“, “tapering AND insomnia“ or “discontinuation AND insomnia“ in combination with the names of drug classes (e.g., benzodiazepines) or individual medications (e.g., zopiclone) as well as the search terms “withdrawal“ and “rebound“. Of the 488 publications initially identified, 122 were included in the review: 17 systematic reviews and meta-analyses, 14 guidelines and consensus recommendations, 32 randomized, controlled trials, 41 observational studies, and 18 case reports. First, meta-analyses were used as the basis for the evidence evaluation to prepare the recommendations. If there were several meta-analyses on the same topic, preference was given to those that were more recent and of higher quality. Where no meta-analyses were available for certain topics, we used systematic reviews or high-quality randomized controlled trials. For the evaluation of the evidence, the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (2009) ranking system was used (e34). We used the classification based on Cohen’s d and Hedges’ g to describe the effect sizes found in the meta-analyses and original studies (0.2–0.5: small effect; 0.5-0.8: moderate effect; 0.8 or higher: large effect).

The first version of the manuscript was prepared by the group of core authors (GH, IF, CS, MS, BH, YW) and submitted to all other contributing authors for comment. After incorporating the feedback received, a consensus conference was held attended by all authors. During this conference, the manuscript was discussed jointly and the recommendations adopted by consensus. The meeting was held as a structured consensus conference following the model of the U.S. National Institutes of Health (modified Delphi method). The recommendations to be voted on were presented in the plenary session. Then there was an opportunity to ask questions and submit well-reasoned proposals for changes. Where necessary, discussions were held before the recommendations and proposed changes were formally agreed upon. Based on the discussions at the consensus conference, the background text of the manuscript was revised. In the next step, this text was further discussed and approved via email.

eFigure.

eFigure

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart for the identification of relevant literature (adapted from [e44]))

This creates new country-specific opportunities for switching strategies in patients with long-term benzodiazepine and Z-drug use. The consensus process was based on the pertinent publications identified and guideline-supported clinical recommendations.

Results

Deprescribing or switching a sleep medication refers to a physician-supported process aimed at discontinuing or switching a treatment. Examples of reasons for this approach include:

  • Fulfilling patient wishes

  • Taking into account the approval status of the medications (an approved duration of use of four weeks for most drugs)

  • Prevention of side effects and disruption of sleep physiology

  • Inadequate effectiveness or loss of effectiveness (occurs in 15–25% of cases) (4, 5, e4).

In patients with short-term (1–2 weeks) or intermittent as-needed use of hypnotic medications, neither specific tapering regimens nor special measures are required when switching treatments. Table 1 lists the regimens for deprescribing and switching hypnotic medications, as determined by the consensus process. How these regimens are carried out in clinical practice is shown in the Figure. The following recommendation applies to all drug classes: The deprescribing process can be supported by concomitant or subsequent behavioral therapy (for example, cognitive behavioral therapy for insomnia [CBT-I]), or elements thereof, with a psychotherapist or using digital health applications) (e5, e6). Indications for CBT-I include the use of hypnotic medications over a period of more than six weeks, substance dependence and mental comorbidity. The best evidence supporting the use of concomitant CBT-I is available for deprescribing benzodiazepines and Z-drugs (meta-analysis of eight randomized, controlled trials [RCTs]: relative risk [RR]: 1.68; 95% confidence interval: [1.19; 2.39]; p = 0.003 compared to deprescribing without CBT-I) (6).

Table 1. Evidence- and experience-based methods of deprescribing and switching hypnotic medications.

Method Level of evidence*1 Practical implementation /effect size*2 [95% CI]
Discontinue abruptly; possibly switch immediately
(“stop“ or “stop and switch“)		 1b Use of the current medication is discontinued, and the new medication is started at the standard therapeutic dose the following day. Recommended with short-term use (< 2 weeks) or for medications not causing withdrawal symptoms (daridorexant and other orexin receptor antagonists, melatonin, phytotherapeutics) (Figure 1: A).
Effect size: 0.37 [0.18; 0.59] (12, e30–e33, e36–e41)
Slow taper 1a Gradual dose reduction is accomplished by gradually (“step taper”) or dynamically (“hyperbolic taper“) lowering the administered dose.
This occurs typically over a period of 4 weeks, or over months following years of use (Figure 1: B, C). Effect size: 0.31 [0.14; 0.40] (14, e9–e22, e23, e25)
Taper and wait 1–2 days 1a After tapering, there is a waiting period of 1–2 days,—or longer, if needed—before the new medication is started. This approach is preferably taken after discontinuing medications with a long elimination half-life to avoid overlapping interactions (Figure 1: D).
Effect size: 0.28 [0.15; 0.46] (e9–e22, e42, e43)
Cross taper 1b The dose is reduced while a new medication is started at a low dose which is then gradually increased. In case of non-interacting substances, this is done to prevent possible withdrawal effects and a recurrence of the sleep disorder by using the hypnotic effect of the new medication (Figure 1: F). Effect size: 0.34 [0.22; 0.52] (17, 19, 20, e29–e34)
Taper or stop and wait watchful 5 After gradual or abrupt discontinuation, no new medication is started, but the course of the sleep disorder is carefully monitored for possible remission. Pharmacotherapy is initiated upon recurrence of symptoms that require treatment (Figure 1: E).
Add and taper 1b The new hypnotic medication is started at a maintenance dose or at a low dose which is then increased rapidly, while the medication to be discontinued is tapered off. The new medication should be interaction-neutral (daridorexant and other orexin receptor antagonists, melatonin, phytotherapeutics) (Figure 1: G). Effect size: 0.36 [0.19; 0.55] (12, e30–e34)
Reduce and combine 5 After dose reduction, the baseline medication is maintained at a lowered dose and combined with a new hypnotic medication administered at a low dose. The dose of the baseline medication is gradually tapered off to the minimum effective dose; intermittent sleep problems are controlled using a newly administered hypnotic medication. Whenever possible, the new medication should be administered intermittently “as needed”, rather than daily (Figure 1: H, I).
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*1

The levels of evidence were defined according to the 2009 Oxford Centre for Evidence-Based Medicine ranking system (e34)

*2

Relative risk of resuming the discontinued medication after successful discontinuation or switch. Effect size of level 5 evidence is not stated. [95% CI], 95% confidence interval; CBT-I, cognitive behavioral therapy for insomnia

Figure.

Figure

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Regimens for deprescribing and switching hypnotic medications (For detailed explanations, see Table 1)

Recommendations on deprescribing and switching benzodiazepines

An analysis of studies and meta-analyses (4) confirms the clinical observation that 20–30% of patients with 4–6 weeks of benzodiazepine use and 50–70% of patients with several months of benzodiazepine use develop mental and physical withdrawal symptoms after abrupt discontinuation, including inner restlessness, anxiety, tremor, headache, and muscle pain, as well as rebound insomnia with worsening of the sleep disorder compared to baseline levels (e7, e8). Severe withdrawal symptoms requiring inpatient treatment include epileptic seizures, delusions, hallucinations, and delirium (e9). Guidelines recommend that benzodiazepines should generally be discontinued in persons over the age of 65 years, because the benefit-risk profile is unfavorable in this age group due to elevated benzodiazepine-associated hospitalization rates (hazard ratio [HR]: 1.1 [1,1; 1.2]) and mortality rates (HR: 1.3 [1.2; 1.4]) (7). During the deprescribing process, the medication should be tapered off gradually (4, 5, 8). The recommendations are summarized in Box 1.

Box 1. Recommendations on deprescribing or switching benzodiazepines.

  • No specific discontinuation or switch protocols are required in the case of short-term (1–2 weeks) or intermittent, as-needed use.

  • In the case of medium- and long-term use (> 2 weeks), benzodiazepines should be tapered off gradually until discontinued completely; this can potentially be achieved without specific, accompanying therapy.

  • If withdrawal symptoms occur, benzodiazepine tapering can be facilitated by overlapping gradual introduction of other hypnotic medications (“cross tapering“) (4, 5).

  • Standard tapering regimens involve a gradual dose reduction by 25% every 1–2 weeks until the medication is stopped completely (4).

  • As an alternative, a weekly dose reduction of 25% for the first 75% of the dose, followed by hyperbolic tapering at steps of 12.5% for the last 25% of the dose, can be employed.

  • Especially after years of use and/or high-dose administration, benzodiazepines should be tapered off at a much slower rate; if necessary, over a period of months: 5–10% of the daily dose every 2–4 weeks (e10, e11).

  • Switching from tablets to a liquid dosage form of a benzodiazepine can facilitate a gradual, drop-by-drop reduction in dosage, particularly in the final third of the dose.

  • If CBT-I is not effective or unavailable, discontinuation can be facilitated by overlapping gradual introduction of another hypnotic medication or switching to it (4). This has been shown for:
    • –
      Orexin receptor antagonists (e.g., daridorexant) (5).
    • –
      Z-drugs, especially eszopiclone, given its low risk of dependence
    • –
      Melatonin receptor agonists; the effectiveness of in Germany and Austria available prolonged-release melatonin was shown in open studies
    • –
      Gabapentinoids (e.g., pregabalin)
    • –
      Sedative antidepressants, such as doxepin
    • –
      Other benzodiazepines: Only in exceptional cases, such as when switching from an anxiolytic (e.g., alprazolam, lorazepam) to a benzodiazepine with a more pronounced hypnotic effect (e.g., lormetazepam, temazepam)

  • In some studies, however, switching to a new medication at the optimal effective dose led to increased sedation and hangover effects in the morning when benzodiazepines and Z-drugs were used (4) so that an overlapping gradual dose-decreasing and dose-increasing regimen appears more appropriate for these medications (cross taper).

Recommendations on deprescribing or switching Z-drugs

While the Z-drugs zolpidem, zopiclone and eszopiclone are benzodiazepine receptor agonists, their chemical structure and clinical effects differ from those of classical benzodiazepines. This is particularly true of zolpidem and eszopiclone, which cause less pronounced withdrawal effects compared to benzodiazepines, presumably due to their selective action on α1β2γ2 GABAA receptors (e9). Withdrawal symptoms such as anxiety attacks, restlessness, agitation, or daytime sleepiness are rarely seen with Z-drugs (4). Eszopiclone was developed from zopiclone and is characterized by improved receptor affinity. A Cochrane analysis reported no clinically significant withdrawal symptoms for eszopiclone (9). The practical recommendations on switching medication and deprescribing Z-drugs are summarized as follows:

  • In motivated patients, abrupt discontinuation of Z-substances is possible when the treatment dose is low (<half the maximum approved dose) and/or the duration of use is short (1–2 weeks) (3, 4).

  • Patients wishing to stop taking Z-drugs but are less motivated and/or those taking a high dose (half or more of the maximum approved dose) or using the medication for a medium- or long-term period (>2 weeks) should slowly taper off Z-drugs until they have completely discontinued their use (Table 1) (3). This strategy is also recommended for patients with comorbidities or a history of withdrawal syndrome.

  • A gradual tapering regimen is recommended, with a 25% dose reduction every 1–2 weeks or longer until the medication is discontinued (e10, e11).

  • A medication-free period of one to two days is recommended between the discontinuation of a Z-drug and the start of a new hypnotic medication (Table 1) (3).

  • Withdrawal symptoms (e.g., mood swings, irritability, anxiety, sweating, tremors, muscle cramps) or the recurrence of disordered sleep, which may occur when a Z-drug is tapered off, can be alleviated with the overlapping gradual introduction of other hypnotic medications (Table 1) (3).

  • Adherence to the withdrawal regimen is significantly improved by informing patients about the risks associated with their current medication, alternative treatment options, and potential withdrawal symptoms, such as anxiety, restlessness, agitation, and transient rebound insomnia (e12, e13).

  • Switching from one Z-substance to another can be carried out abruptly (3).

Recommendations on deprescribing or switching dual orexin receptor antagonists

Daridorexant is the first dual orexin receptor antagonist (DORA) approved for the treatment of chronic insomnia in Europe. It differs from the DORAs approved for use in the United States in that it has a different degree of binding affinity for the orexin receptors 1 and 2 as well as a shorter elimination half-life (10).

For the DORA drug class, several randomized controlled clinical trials are available that evaluated controlled discontinuation after treatment periods of up to one year (4, 11–13). No withdrawal symptoms were observed with daridorexant, which is available in Europe, and lemborexant, which is approved for use in the United States. Daridorexant was shown to have a sustained effect without tolerance development for up to one year, an absence of discontinuation/withdrawal symptoms upon abrupt stopping of the medication after a treatment period of up to 12 months (13), and no rebound insomnia (13). Based on this data, it can be concluded that DORAs such as daridorexant can be abruptly discontinued even after prolonged use (4, 5).

The recommendations on deprescribing or switching DORAs are as follows:

  • Daridorexant, which is available in Germany and Austria, can be discontinued abruptly without causing clinically significant withdrawal symptoms or rebound insomnia even after months of use (4, 5, 11, 13).

  • Nevertheless, consideration should be given to informing these patients of the possibility that their sleep pattern may temporarily change after discontinuing the medication.

  • Patients can start taking other hypnotic medications immediately on the night following discontinuation (4, 5).

Recommendations on deprescribing or switching melatonin

The literature on synthetic melatonin receptor agonists (e.g., ramelteon) includes controlled studies on discontinuation that found no discontinuation and withdrawal symptoms after up to six months of treatment and no rebound insomnia (4, 5). The controlled deprescribing studies evaluating melatonin products available in Europe are of poor quality. Evidence from controlled trials that discontinuing melatonin does not give rise to withdrawal symptoms or rebound insomnia is only available from studies evaluating prolonged-release melatonin for insomnia (14, 15). Agomelatin is approved for the treatment of depression. It will be discussed in the following section in connection with the use of antidepressants. Based on the data mentioned above, the following recommendations can be made:

  • Melatonin can be abruptly discontinued.

  • Other hypnotic medications can be seamlessly taken the night after discontinuation.

  • Overlapping gradual introduction of another hypnotic medication is permitted (Table 1).

Recommendations on deprescribing or switching antidepressants with hypnotic action

As a general rule, discontinuing antidepressants taken at doses used to treat depression may lead to withdrawal symptoms (16); these occur more frequently with serotonin or serotonin-norepinephrine reuptake inhibitors compared to hypnotic medications (17). They are significantly more commonly observed with paroxetine (31.6%) and duloxetine (26.9%) compared to mirtazapine (0.9%), doxepin (0.2%), agomelatine (0.004%), and trimipramine (0.007%) (18).

Symptoms upon discontinuation of antidepressants, which are also used to treat insomnia, have rarely been investigated. Recommendations on managing this drug class are as follows:

  • Due to a low risk of withdrawal symptoms with lowdose therapy, trimipramine, mirtazapine, trazodone, and doxepin can be discontinued abruptly (19, 20)

  • Agomelatin carries no risk of withdrawal symptoms and can thus be discontinued abruptly (17).

  • Patients should be advised that sleep quality may deteriorate in the days following discontinuation.

  • Other hypnotic medications can be introduced gradually in an overlapping manner or immediately at the optimum effective dose. Here, additive sedative effects must be taken into account (“add and taper“ or “reduce and combine“).

Recommendations on deprescribing or switching hypnotic antipsychotics

Sedative and hypnotic antipsychotics (e.g., olanzapine, pipamperone, melperone, and risperidone) are primarily used to treat patients with mental illness associated with a sleep disorder. In Europe, quetiapine is increasingly used off-label to treat insomnia in patients with no psychiatric or neurological comorbidities. According to the available study data, the risk of recurrence of psychotic symptoms upon discontinuation of antipsychotics exceeds 50% (8). However, the effects of discontinuation of low-dose antipsychotic treatments for chronic insomnia have not yet been studied (8). An analysis of the World Health Organization’s pharmacovigilance database found that quetiapine is associated with a higher risk of withdrawal symptoms compared to other antipsychotics (21). The recommendations for this drug class are as follows:

  • Antipsychotics that were prescribed for their expected hypnotic effects should be tapered off gradually (Table 1).

  • Should withdrawal symptoms (such as restlessness, anxiety, mood swings) occur, another hypnotic medication can be gradually introduced (Table 1). This applies in particular to medications such as quetiapine, where withdrawal symptoms tend to be more common.

  • Should sleep disturbances recur, another hypnotic medication may be used 1–2 days after discontinuation (Table 1).

Recommendations on deprescribing or switching hypnotic gabapentinoids

Gabapentinoids used off-label for insomnia (pregabalin and gabapentin) must be discontinued with special care, as anxiety and pain may recur with increased intensity (22). In addition, gabapentinoids have the potential for abuse and dependence and can cause anxiety symptoms and rebound insomnia upon discontinuation (22). Therefore, the dose should be reduced gradually. Here, the recommendations are as follows:

  • In patients with sleep disorders, gabapentinoids (pregabalin and gabapentin) should be tapered off gradually (Table 1)

  • Depending on the symptoms that are most prominent in the individual patient experiencing withdrawal symptoms (such as nervousness, irritability, anxiety, depression, headache, tremors, increased sweating), another hypnotic medication can be gradually introduced to overlap with the gabapentinoid treatment; in patients with comorbidities, an additional anxiolytic or analgesic medication may also be needed (Table 1).

Recommendations on discontinuing or switching over-the-counter antihistamines and phytotherapeutics

Given the lack of adequate evidence regarding the effectiveness of hypnotic antihistamines and natural sleep aids, sleep medicine guidelines do not cover the issue of discontinuing their use (2–5). Some phytotherapeutics, such as passionflower, bind to benzodiazepine receptors and thus could potentially cause withdrawal symptoms (23). However, antihistamines and the majority of herbal medicines have only a mild hypnotic effect, making clinically significant withdrawal symptoms unlikely. This particularly applies to plant extracts such as hops, lavender and lemon balm. According to case reports, discontinuation of valerian use in high doses caused marked withdrawal symptoms (24, e14); thus, a gradual tapering off is recommended for patients taking doses of more than 1000 mg per day. The recommendations are as follows:

  • Since antihistamines and phytotherapeutics have low clinical potency, they can be discontinued abruptly.

  • Given the increased risk of withdrawal symptoms, a gradual dose reduction is recommended for patients taking high-dose valerian preparations (> 1000 mg/day) (Table 1).

Table 2 summarizes the findings described above.

Table 2. Recommendations on switching hypnotic medication.

Original drug class/group Recommendations on switching to another drug class Level of evidence*1 Effect size*2 [95% CI] Recommendations on switching within one drug class Level of evidence*1 Effect size*2 [95% CI]
Benzodiazepines Slowly gradually/ overlapping (e18, e20–e22, e25, e35) 1b 0.32 [0.15; 0.49] Direct switch (e23, e24) 1a 0.41 [0.31; 0.83]
Z-drugs Slowly gradually and then wait for 1–2 days/ overlapping (14, e21) 1a 0.34 [0.18; 0.65] Slowly gradually and then wait for 1–2 days/ overlapping (14, e21, e26) 1a 0.38 [0.27; 0.71]
Daridorexant Direct switch (11–13) 1b 0.24 [0.11; 0.43] Direct switch (11, e27) 1b 0.27 [0.14; 0.41]
Mirtazapine Slowly gradually/ overlapping 5 Not applicable Not recommended 5 Not applicable
Trazodone Slowly gradually/ overlapping 4 Not applicable Not recommended 5 Not applicable
Doxepin Direct switch (e28, e29) 1b 0.35 [0.20; 0.69] Not stated 5 Not applicable
Agomelatine Direct switch 4 Not stated 5 Not applicable
Other and higher dosed tricyclic antidepressants Slowly gradually/ overlapping 4 Not applicable Not recommended 5 Not applicable
Quetiapine and other antipsychotics Slowly gradually/ overlapping 4 Not applicable Direct switch, e.g., quetiapine immediate release to prolonged release 5 Not applicable
Pregabalin, gabapentin Slowly gradually / overlapping 5 Not applicable Direct switch 5 Not applicable
Melatonin Direct switch (e30–e33) 2b 0.21 [0.12; 0.54] Direct switch, e.g., immediate release to prolonged release 4 Not applicable
Antihistamines Direct switch 5 Not applicable Not recommended 5 Not applicable
Valerian phytotherapeutics Slowly gradually/ overlapping 5 Not applicable Direct switch, possibly from ethanol-extracted to methanol-extracted substance 5 Not applicable
Other herbal medicines Direct switch 5 Not applicable Direct switch 5 Not applicable
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*1

Levels of evidence were defined according to the 2009 Oxford ranking system t (e34).

*2

Relative risk of renewed use of the discontinued medication after completion of the switch [95% CI], 95% confidence interval

Discussion

The sleep medicine guidelines recommend CBT-I as the first-line treatment for insomnia. If CBT-I does not achieve an adequate response or is not available, pharmacotherapy may be considered (2, 3). For short-term use (≤ 4 weeks), hypnotic medications can generally be used with good results, provided that the risks and side effects are taken into account.

If long-term pharmacotherapy with hypnotics is planned, preference should be given to medications with a proven long-term effect and no or low potential for dependence, such as dari-dorexant or eszopiclone. Long-term treatment with other hypnotic medications is associated with long-term risks, such as the development of drug tolerance, an increased risk of falls, cognitive impairment, behavioral changes, persistent changes in sleep architecture, and the development of dependence (e15, e16). Many affected patients become aware of their dependence only after they are already dependent on their hypnotic medication (e17). For this reason, physicians should encourage patients to refrain from long-term pharmacotherapy, by transparently discussing the risks associated with pharmacotherapy and prompting them to engage in self-reflection. Physicians should offer patients a trial of discontinuing pharmacotherapy and replacing or supplementing it with non-pharmacological alternatives that help with sleep problems, in particular CBT-I (e18).

If prolonged pharmacotherapy cannot be avoided, switching to medications with a more favorable long-term efficacy and risk profile should be considered. Care should be taken when switching or discontinuing hypnotic medications, as this can lead to withdrawal symptoms and recurrence of insomnia. Accompanying or subsequent psychotherapy and/or, if needed, medical supervision can/should always be considered. As a general rule, subsequent treatment with other medications should not be started before discontinuation of the initial medication in order to prevent that the effectiveness is impaired by withdrawal symptoms. Where appropriate, a combination of low-dose hypnotic medications may be considered temporarily during tapering, particularly in patients at high risk of relapse or severe withdrawal symptoms. The potential accumulation of side effects should be discussed with patients before initiating combination therapy.

Further details on how to clinically implement the various treatment regimens shown in the Figure are provided in the sleep medicine textbook “Kompendium Schlafmedizin” (25).

GABAergic medications, such as benzodiazepines, Z-drugs and gabapentinoids, should always be tapered off gradually. This also applies to antidepressants and antipsychotics. Modern third-generation hypnotics, such the dual orexin receptor antagonist daridorexant, can be discontinued abruptly.

Acknowledgement

The following members of the Insomnia Working Group of the German and Austrian Societies for Sleep Research and Sleep Medicine contributed to the preparation of this manuscript (Collaborators):

Prof. Dr. med. Jens Kuhn, Department of Psychiatry and Psychotherapy, University Hospital Cologne, Alexianer Köln GmbH, Collogne, Germany

Prof. Dr. med Hans-Jörg Assion, LWL-Klinik Dortmund, Dortmund, Germany

Dr. med. Dirk Czesnik, Group Practice for Neurology, Psychiatry and Psychotherapy, Göttingen, Germany

Dr. med. Sebastian Herberger, ProSomno Klinik, Munich, Germany. Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany

Prof. Dr. med. Kai G. Kahl, Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany

Dr. med. Christina Lang, Department of Neurology, Ulm University Hospital, Ulm, Germany

Dipl.-Psych. Markus B. Specht, DKD Helios Hospital Wiesbaden, Center of Interdisciplinary Sleep Medicine, Wiesbaden, Germany

Dr. med. Stefan Ries, NeuroCentrum Odenwald, Erbach, Germany

Dr. phil. Dipl.-Psych. Julia Lechinger, Center of Integrative Psychiatry (ZIP), University Hospital Schleswig-Holstein (UKSH), Kiel, Germany

Footnotes

Conflict of interest statement: GH received lecture and consulting fees from Amgen, Astra-Zeneca, Berlin-Chemie, Boehringer Ingelheim, Hennig, Idorsia Johnson & Johnson, Recordati, Rovi, Schwabe, Simcere, and Takeda.

IF received lecture fees from Hennig, Idorsia, Berlin-Chemie, and Stada, as well as travel expense support from Idorsia.

CS received consulting and lecture fees from ResMed, AstraZeneca, BerlinChemie, Boehringer Ingelheim, Bristol-Myers Squibb, Jazz Pharma, Mementor, Novartis, Zoll, Idorsia, Bayer, Lilly, Takeda, Bioprojet, Chiesi, and Inspire.

MS received lecture and consulting fees from Idorsia Pharmaceuticals, Pharmanovia, Takeda, and Lilly.

BH received lecture fees from Idorsia and Takeda as well as travel expense support from Idorsia, Takeda and Jazz.

YW received lecture and consulting fees from Angelini Pharma, Arvelle Therapeutics, Bayer AG, BIAL, Bioprojet, Eisai, Hennig, Idorsia Pharmaceuticals, JAZZ Pharmaceuticals, LivaNova, Novartis, and UCB Pharma.

Supplementary material

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eTable. Overview of the levels of evidence according to the Oxford ranking system (2009) (e34).

Evidence level Study design (Therapy/Prevention) Significance
1a Systematic reviews (meta-analyses) Homogeneous randomized controlled trials (RCTs) Highest evidence
1b Individual high-quality randomized controlled trial (RCT) with narrow confidence interval Very high evidence
1c All-or-none studies Very high evidence
2a Systematic reviews of homogeneous cohort studies High evidence
2b Individual cohort study or limited-quality RCT Good evidence
2c “Outcomes” research or ecological studies Moderate evidence
3a Systematic reviews of homogeneous case-control studies Limited evidence
3b Individual case-control study Limited evidence
4 Case-series or poor quality cohort and case-control studies Low evidence
5 Expert opinion, pathophysiological considerations, bench research, or “first principles” Lowest evidence
Open in a new tab

Questions regarding the article in issue 19/2026: Recommendations on Switching or Deprescribing Hypnotic Medications for Insomnia

The closing date for entries is 17 September 2027. Only one answer is possible per question.

Please select the answer that is most appropriate.

  • Question 1

    A 58-year-old patient has used a Z-drug regularly for several months to treat chronic insomnia. He would like to discontinue the medication. Which accompanying measure is backed by the best evidence?
    1. Counseling on sleep hygiene alone
    2. Cognitive behavioral therapy for insomnia
    3. Temporary use of lorazepam
    4. Prophylactic antipsychotic treatment
    5. A routine polysomnographic follow-up examination

  • Question 2

    A 71-year-old female patient has been taking a benzodiazepine in high doses as a sleep aid for three years. Which deprescribing regimen is most appropriate to recommend?
    1. Discontinuing abruptly without accompanying measures
    2. Dose reduction by 50% every three days
    3. Daily dose reduction of 25%
    4. Reduction of daily dose by 5–10% every two to four weeks
    5. Switching to intermittent use of the same dose

  • Question 3

    Which symptoms are considered severe benzodiazepine withdrawal symptoms requiring inpatient treatment?
    1. Headache, muscle pain and restlessness
    2. Rebound insomnia and temporary irritability
    3. Daytime fatigue and problems concentrating
    4. Epileptic seizures, hallucinations and delirium
    5. Dry mouth, constipation and weight gain

  • Question 4

    A motivated patient used zolpidem for ten days at a lower dose than prescribed. He has no significant comorbidities and no history of withdrawal syndrome. Which discontinuation regimen is appropriate?
    1. The medication can be abruptly discontinued..
    2. The medication should be tapered off over a period of at least six months.
    3. Prior to discontinuing zolpidem, the patient should be switched to a benzodiazepine.
    4. Inpatient admission for specialist-supervised discontinuation of the medication.
    5. The medication should be continued indefinitely to prevent rebound insomnia.

  • Question 5

    In a patient taking a Z-drug, it is planned to switch to a different medication without any overlap once the current medication has been completely tapered off. How long is the generally recommended break before starting the new medication?
    1. From a sleep medicine perspective, such a break would be considered inappropriate.
    2. Six to twelve hours
    3. One to two days
    4. Seven days
    5. Two weeks

  • Question 6

    A female patient has been taking daridorexant for ten months. It is planned to discontinue the treatment. Which statement is true?
    1. Daridorexant should always be tapered off over a period of several months.
    2. Daridorexant can be discontinued abruptly.
    3. Discontinuation must only be attempted in an inpatient setting.
    4. After prolonged use, a severe withdrawal syndrome can generally be expected.
    5. Before the medication is discontinued, the patient must be switched to a Z-drug for overlapping use.

  • Question 7

    According to the data presented in the article, which of the following antidepressants shows no significant risk of withdrawal symptoms and can generally be discontinued abruptly?
    1. Paroxetine
    2. Duloxetine
    3. Mirtazapine
    4. Trimipramine
    5. Agomelatine

  • Question 8

    Quetiapine was prescribed off-label for chronic insomnia to a female patient without psychotic illness. It is planned to discontinue the treatment. Which regimen is appropriate according to the recommendations?
    1. In general, quetiapine can be discontinued abruptly, regardless of the dose.
    2. The dose should initially be increased and then treatment should be discontinued abruptly.
    3. Quetiapine should be tapered off gradually; if withdrawal symptoms occur, another hypnotic substance can be introduced gradually in an overlapping manner..
    4. Switching to a different antipsychotic medication is absolutely necessary.
    5. Quetiapine should be continued indefinitely due to the generally high risk of recurrence of psychosis.

  • Question 9

    Which of the following statements about discontinuing pregabalin or gabapentin treatment for sleep disorders is true?
    1. Gabapentinoids carry no risk of abuse or dependence.
    2. These medications can be discontinued abruptly, regardless of the dose or duration of use.
    3. They should be tapered off gradually, as withdrawal symptoms such as anxiety, pain and rebound insomnia may occur.
    4. When discontinuing these medications, only gastrointestinal symptoms are to be expected.
    5. Prior to discontinuation, patients must always undergo inpatient withdrawal treatment.

  • Question 10

    Which statement about discontinuing over-the-counter hypnotic medications is true?
    1. All phytotherapeutics must be tapered off slowly.
    2. Antihistamines are regularly associated with severe withdrawal symptoms.
    3. Hop, lavender and lemon balm preparations generally require cross-tapering.
    4. Treatment with high doses of valerian (more than 1000 mg per day) should be tapered off gradually.
    5. Valerian can always be abruptly discontinued, regardless of the dose.

References (abbreviated)

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