The use of short‐ and long‐acting hypnotics in clinical medicine.

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Abstract
1 Activity of short‐ and long‐acting benzodiazepines is reviewed with reference to pharmacokinetics and residual sequelae, and to efficacy and adverse effects. 2 Some benzodiazepines may not lead to obvious effects on performance, such as nordiazepam and clobazam, and the persistence of residual sequelae may not relate obviously to elimination half‐lives (as with diazepam and possibly flunitrazepam). However, benzodiazepines with mean half‐lives less than 8 h may have residual sequelae, whereas hypnotics with mean half‐lives greater than 16 h are likely to lead to impared performance and/or anxiolytic effects the next day. 3 Potassium chlorazepate 15 mg, with its long‐ acting metabolite nordiazepam, would seem to be the drug of choice for insomnia secondary to anxiety. For the insomniac without significant psychopathology, temazepam 10‐20 mg, triazolam 0.125‐0.25 mg and for occasional use, diazepam 5‐10 mg, provide the initial approach. Flurazepam hydrochloride 15‐30 mg, nitrazepam 5‐10 mg and flunitrazepam 1 mg and above, have persistent residual effects and should be reserved for refractory patients, and for those in whom some impairment of performance the next day would be acceptable. 4 There is little or no evidence to suggest that the proper use of the short‐acting hypnotics, triazolam and temazepam, leads to a worsening of sleep on withdrawal. However, some benzodiazepines may lead to disturbances of sleep and/or rebound insomnia, and nitrazepam and flunitrazepam may be implicated.