Recommendations on Switching or Deprescribing Hypnotic Medications for Insomnia.

Abstract

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, evidence-based recommendations that take account of specific aspects of care both in Europe as a whole and regionally. 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. 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 longer 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. Cognitive behavioral therapy is recommended as an accompanying nonpharmacological treatment (relative risk [RR]: 1.68; 95% confidence interval: [1.19; 2.39]). A drug-specific approach with evidence-based and practice-oriented protocols should be used when hypnotic medications are switched or discontinued.