Sedative hypnotics are commonly used to aid sleep disorders such as insomnia. These drugs are generally licenced for short term use in sleep disorders. However, some patients may use hypnotics for long term treatment of sleep disorders, and other conditions. In such cases, patients should be regularly reviewed, and consideration should be given to withdrawing hypnotics as soon as is clinically suitable.

Deprescribing of hypnotic drugs should always take place following a process of shared decision making between the prescriber and the patient. Consideration should be given to a broad range of factors in the patient’s life which may influence the successful timing of a deprescribing plan. Throughout the process of withdrawal, prescribers should ensure that they offer continued management of the underlying condition for which the medicine was prescribed.

All discussion regarding the deprescribing of hypnotics should be clearly documented alongside the plan for dose reduction or withdrawal in the overall management plan.

The following guidance provides some key considerations for deprescribing hypnotic drugs.

Reviewing prescriptions initiated in secondary care

Some patients may need to take a hypnotic whilst they are in hospital. Patients discharged from local hospitals should not receive a supply of hypnotics unless it can be clearly established that ongoing treatment is required.

Prescribers in secondary care should review all prescriptions for hypnotics on discharge for appropriateness and ensure there is clear communication for GPs regarding whether hypnotics should be continued. Where a specialist recommends that treatment with a hypnotic is continued past the usual maximum treatment duration (i.e. off-label) a clear rationale must be communicated to the GP, including a proposed treatment plan of when to review, reduce and/or discontinue treatment.

Deprescribing benzodiazepines and z-drugs

NICE NG215 (April 2022) provides recommendations regarding safe prescribing and withdrawal management for adults receiving benzodiazepines and z-drugs.

NICE has also produced a clinical knowledge summary which details best practice for the withdrawal of benzodiazepines and z-drugs (including suggested withdrawal schedules and guidance on switching to diazepam).

The following key principles should be considered when developing a deprescribing plan with a patient:

• Patients being prescribed benzodiazepines and/or z-drugs should be regularly reviewed (by phone, video or face to face).
• When reviewing a patient receiving benzodiazepines and/or z-drugs, a deprescribing plan should be discussed and agreed when:
  • The treatment is no longer benefiting the person
  • Problems associated with dependence have developed
  • The condition for which the medicine was prescribed has resolved
  • The harms of the medicine outweigh the benefits
  • The person wants to stop taking the medicine
• NICE has produced a patient decision aid which may be useful when discussing the withdrawal of benzodiazepines or z-drugs with a patient.
• Following long term use (>4 weeks), benzodiazepines and z-drugs should not be stopped abruptly (complete cessation with immediate effect) unless there are exceptional medical circumstances, such as the occurrence of serious side effects.
• Before starting the withdrawal ensure that the patient is aware of:
  • The process of withdrawal and how it is to be tailored to their situation and medicine they are receiving.
  • Sources of peer support such as local and national groups providing support for individuals withdrawing from a medicine.
  • Withdrawal symptoms and how long these may last and vary in type and severity between individuals.
• The dose reduction schedule should be agreed with the patient, the prescriber should:
  • Explain the risks involved with immediate cessation and detail how withdrawal effects may differ between people.
  • Balance the risks of adverse effects from continued treatment with the likely effects of withdrawal and consider a suitable dose reduction rate.
  • Ensure the patient agrees with the rates of dose reduction.
  • Agree regular reviews throughout and after the deprescribing process.

Deprescribing melatonin

Data for the efficacy of long term (>13 weeks) treatment with melatonin are lacking. Evidence from clinical trials suggests that withdrawing melatonin after a successful course of treatment is unlikely to result in a reoccurrence of the symptoms which it was initially used to treat.

For some indications such as the management of rapid eye movement behaviour disorder in patients living with Parkinson’s disease, treatment with melatonin may be ongoing and long term. In such cases, it is expected that the specialist team who initiated the treatment should continue to provide ongoing supervision, including periodic review.

There are some indications where melatonin is recommended in children and young people, but use in adults is “off-label” and non-formulary. During the transition between child and adult services, consideration should be given to whether continued treatment with melatonin is suitable. Individuals who continue to receive melatonin once they transfer into adult services should be periodically reviewed by the specialist team. The specialist teams should communicate to prescribers in primary care the frequency of the review. At each review consideration should be given to the need for ongoing treatment and the potential for deprescribing melatonin.

The specialist team should communicate any changes in dosing required directly with prescribers in primary care. When considering treatment cessation for these individuals, prescribers should contact the specialist team for advice.

Deprescribing melatonin in adults using melatonin for the treatment of insomnia.

These key principles are intended to guide the deprescribing of melatonin in adult patients who have received melatonin to treat insomnia.

• Melatonin should only be prescribed for the management of insomnia in adults aged 55 and above. Adults under this age receiving melatonin solely for insomnia should be reviewed and a deprescribing plan should be discussed.
• The maximum treatment course should be 13-weeks.
  • The maximum treatment course should be communicated to the patient at the start of treatment.
  • Any patient receiving melatonin for greater than 13-weeks should be reviewed to discuss and agree a deprescribing plan.
  • When reviewing the patient, highlight the importance of continuing good sleep hygiene.
• A process of shared decision making should be used to agree the deprescribing plan. Patients should be assured that:
  • It is unlikely that insomnia symptoms will reoccur upon withdrawal of melatonin.
  • It is also unlikely that withdrawal effects will be experienced.
  • As such, dose reduction is not required, and treatment may be stopped with immediate effect.
• If insomnia symptoms reoccur following discontinuation of melatonin, the patient should be reassessed; alternative diagnoses, and an alternative approach to therapy should be considered.