Nonbenzodiazepines (), also referred to as Z-drugs (as some of the more well-known drugs begin with the letter "z"), are a class of psychoactive, depressant, sedative, hypnotic, anxiolytic drugs that are benzodiazepine-like in uses. Nonbenzodiazepine pharmacodynamics are similar in mechanism of action to benzodiazepine drugs, acting as GABAA receptor positive allosteric modulators of the benzodiazepine site, and therefore exhibit similar benefits, side effects, and risks. However, nonbenzodiazepines have a different chemical structures on a molecular level. Nonbenzodiazepines are addictive. Within days to weeks, the body can become accustomed to their effects. The risk of developing tolerance with nonbenzodiazepine drugs is comparable to benzodiazepines. When the dose is then reduced or the drug is abruptly stopped, withdrawal symptoms similar to those of benzodiazepine withdrawal may result. Nonbenzodiazepines are sometimes used in insomnia. Nonbenzodiazepines decrease sleep latency by 10 to 20 minutes. However, no benzodiazepine-like drug has shown clinically significant increase in total sleep time. Nonbenzodiazepines is recommended only to be taken at the lowest effective dose, with a duration of 2–3 weeks, for short-term insomnia. Use of nonbenzodiazepines more than 4 weeks is not recommended. It is dangerous to take nonbenzodiazepines with benzodiazepines, sedatives, alcohol or other drugs affecting the central nervous system.
Medical uses Z-drugs are used for the short-term treatment of insomnia where difficulty with sleep initiation or sleep maintenance are prominent symptoms. Long-term use is not recommended, as tolerance, dependence, and addiction can occur. Z-drugs decrease sleep latency by 10 to 20 minutes. However, no Z-drug has shown clinically significant increase in total sleep time which is defined as at least 30 minutes. Tolerance develops within days to weeks. The risk of developing tolerance with Z-drugs is comparable to benzodiazepines. Z-drugs are recommended to be taken at the lowest effective dose, with a duration of 2–3 weeks, for short-term insomnia. Use of Z-drugs more than 4 weeks is not recommended. Caution must be taken when Z-drugs are used in conjunction with benzodiazepines, sedatives, alcohol or other drugs affecting the central nervous system. Cognitive behavioral therapy has been found to be superior to Z-drugs in the treatment of insomnia and has been found to have lasting effects on sleep quality for at least a year after therapy. A 2004 meta-analysis of randomised controlled clinical trials that compared benzodiazepines to Z-drugs found few clear and consistent differences between zopiclone and the benzodiazepines in sleep onset latency, total sleep duration, number of awakenings, quality of sleep, adverse events, tolerance, rebound insomnia, and daytime alertness.
Elderly A 2006 review regarding the management of insomnia and the elderly found that considerable evidence of the effectiveness and lasting benefits of nondrug treatments for insomnia exist. Compared with the benzodiazepines, the nonbenzodiazepine sedative-hypnotics offer few if any advantages in efficacy or tolerability in elderly persons. Other agents such as the melatonin receptor agonists may be more suitable and effective for the management of chronic insomnia in elderly people. Long-term use of sedative-hypnotics for insomnia lacks an evidence base and is discouraged for reasons that include concerns about such potential adverse drug effects as cognitive impairment (anterograde amnesia), daytime sedation, motor incoordination, and increased risk of motor vehicle accidents and falls.
Classes
Currently, the major chemical classes of nonbenzodiazepines are: Imidazopyridines
Alpidem Necopidem Saripidem Zolpidem (Ambien, Ambien CR, Intermezzo, Zolpimist, Edluar, Ivadal, Sanval, Stilnox, etc.) Pyrazolopyrimidines
Divaplon Fasiplon Indiplon Lorediplon Ocinaplon Panadiplon Taniplon Zaleplon (Sonata, Starnoc, Andante)
Pharmacology The nonbenzodiazepines are positive allosteric modulators of the GABAA receptor. Like the benzodiazepines, they exert their effects by binding to and activating the benzodiazepine site of the receptor complex.
Functional selectivity Some nonbenzodiazepines can be subtype-selective, possibly providing anxiolytic effects with little to no hypnotic or amnesic effects or providing hypnotic effects with little or no anxiolytic effect. Non-sedating anxiolytic drugs derived from the same structural families as the Z-drugs have been developed, such as alpidem, indiplon, pagoclone and suriclone. A number of non-sedating benzodiazepine anxiolytics such as imidazenil and clobazam also exist, with the caveat that neither is a traditional 1,4-benzodiazepine. The functional selectivity is not unique to the nonbenzodiazepine structural class and has more to do with selectivity among different types of GABAA receptors or partial agonism, though this structural class does have more drug candidates.
Pharmaceuticals The first three nonbenzodiazepine drugs to enter the market were the "Z-drugs": zopiclone, zolpidem and zaleplon. Initially thought to compared to the benzodiazepines, have less of a tendency to induce physical dependence and addiction, although these issues can still become a problem. This has led to the Z-drugs becoming widely prescribed for the treatment of insomnia particularly in elderly patients. Long-term use is not recommended as tolerance and addiction can occur. Zolpidem and zaleplon are, in the US, indicated for 7–10 days of use only. Longer periods of use lead to loss of efficacy from tolerance. Tolerance has also been demonstrated with zopiclone, which is indicated for a maximum of 4 weeks of use in New Zealand.
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