Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
BNF Chapter 4: Central nervous system
4.1 Hypnotics and anxiolytics
HypnoticsPatients should be advised to adopt better sleep hygiene and other lifestyle changes, where appropriate. A leaflet advising on sleep hygiene measures is available on CCG website.
Initial prescriptions for hypnotics should be limited to 7-14 days supply and not transferred to repeat without re-assessment of the patient. Tolerance can develop within 3 to 14 days of continuous use and long term efficacy is not assured.
Patients who do not benefit from a first Z-drug are unlikely to benefit from another. Zolpidem has a half life of 2.5 hours, zopiclone 3.5-6.5 hours. Different rules may apply to patients cared for by Somerset Partnership NHS Foundation Trust.
Diazepam may be considered as an alternative especially when using as a benzodiazepine withdrawal therapy.
On March 2nd 2015 a new law was introduced affecting the use of certain medications when driving. It’s illegal in England and Wales to drive with legal drugs in your body if it impairs your driving. even if taken as prescribed by a healthcare professional. This applies (amongst others) to the benzodiazepines: clonazepam, diazepam, flunitrazepam, lorazepam,oxazepam, temazepam.
See here for more
If patient is suffering insomnia as a result of depression, mirtazapine may be a suggested alternative.
First lineZolpidem

Zopiclone

Diazepam
5mg tablets: £1.25
10mg tablets: £1.19
3.75mg tablets: £1.17
7.5mg tablets:£1.17
2mg tablets: £0.75
5mg tablets: £0.78
MHRA warned in May 2014 of the risk of morning drowsiness and reduced driving ability with zolpidem. Link
Second lineMelatonin
As Circadin®
2mg prolonged release tablets £15.39 (30)Circadin® is indicated as monotherapy for the short-term treatment (up to 13 weeks) of primary insomnia characterised by poor quality of sleep in patients who are aged 55 or over.

Circadin may be of benefit to elderly patients at risk of falling, or to patients who drive and are susceptible to next-day drowsiness of z-drugs and benzodiazepines.

It is also approved for use off label in patients with Parkinson's disease related insomnia (PAMM Jan 16) and for hemicrania continua (PAMM Jan 16) where the specialist has stabilised the patient on an effective and tolerated dose.
Third lineTemazepam10mg tablets: £2.32
20mg tablets: £2.32
Treatment should be limited to lowest dose for the shortest period of time.
AnxiolyticsDiazepam2mg tablets: £0.75
5mg tablets: £0.78
Treatment should be limited to lowest dose for the shortest period of time.