Taking Ambien With Sonata

Ann asked

My father was prescribed both Sonata 5mg and Ambien 5mg and I was concerned. Is this a safe combination?

Answer

Ambien (zolpidem) and Sonata (zaleplon) generally are not to be used together as they both work essentially the same way mechanistically and are used for the same purpose, insomnia. Taking both together would be considered a 'therapeutic duplication'.

It is unlikely that taking Ambien and Sonata at the same time confers any significant added benefit and most likely, simply increases the risk of side effects. They are both CNS (central nervous system) depressants and could have additive side effects when used together, such as:

• Excess sedation
• Low blood pressure
• Respiratory depression
• Headache
• Confusion
• Dizziness

The prescribing information for Ambien specifically warns about combining with other CNS depressant drugs:

"Since the systematic evaluations of zolpidem in combination with other CNS-active drugs have been limited, careful consideration should be given to the pharmacology of any CNS-active drug to be used with zolpidem. Any drug with CNS-depressant effects could potentially enhance the CNS-depressant effects of zolpidem."

While there are studies that compare the overall effectiveness and side effect profile of both drugs, I am unaware of any study evaluating the use of both together.

It is possible that the doctor's intent is to use one or the other on a given night as they do have slight differences in their actions and pharmacokinetic profiles (which I discuss in the next section).

Additionally, it may be that the doctor is trying an alternative treatment due to past treatment failures or other extenuating circumstances.

It is important to speak with the doctor that prescribed both medications and make sure that there hasn't been some error in prescribing or understanding directions for use.

Ambien Vs. Sonata

Ambien and Sonata are known as 'non-benzodiazepine' hypnotic drugs, although they work in a way similar to benzodiazepines like Valium and Ativan. They are also known as 'Z' drugs since the generic names of this new generation of hypnotics start with a 'Z'. They include:

• Ambien (zolpidem)
• Sonata (zaleplon)
• Lunesta (zopiclone)

Since you asked about Ambien and Sonata, I will compare these two specifically.

Duration Of Action

Perhaps the biggest difference between Ambien and Sonata is their overall duration of action and 'half-life'.

Ambien has a duration of action of around 8 hours, and a half-life around 2-3 hours.

Sonata has a duration of action of around 4 hours, and a half-life around 1 hour.

One study reported the following:

"Zaleplon [Sonata] is characterised by an ultrashort half-life (approximately 1 hour). Zolpidem [Ambien] and zopiclone [Lunesta] have longer half-lives (approximately 2.4 and 5 hours, respectively)."

So, Ambien not only lasts longer but takes longer to metabolize. This may make it more effective in maintaining sleep, but may also increase the risk of next-day drowsiness and sedation, as several studies have reported:

"The present results demonstrate that zaleplon [Sonata] at the dose of 10 mg is free of residual hypnotic or sedative effects when administered nocturnally as little as 2 h before waking in normal subjects. In contrast, residual effects of zolpidem [Ambien] are still apparent on objective assessments up to 5 h after nocturnal administration, longer than has been reported from studies involving daytime administration."

Onset Of Action

Sonata has a faster onset of action than Ambien. After taking a dose by mouth, maximum concentrations in the blood are seen about 1 hour later.

In contrast, Ambien takes about 90 minutes to reach maximum concentrations.

Which Is Better?

There is really no way to determine 'which is better' as everyone's medical situation is different. It is certainly possible that one drug may work better for a particular individual than another.

They have a similar safety profile, and the main reasons for their use over conventional benzodiazepine drugs are their:

• Lack/low incidence of withdrawal symptoms.
• Decreased chance of tolerance when compared to benzodiazepines.
• Low incidence of withdrawal symptoms at recommended doses.

The National Institute for Health and Care Excellence (NICE) in the UK conducted a comprehensive review of the 'Z' drugs and recommended the following:

"It is recommended that, because of the lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the short-acting benzodiazepine hypnotics, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed. The drugs with higher acquisition costs should only be prescribed if an individual is intolerant to the first-line choice."

Some studies suggest that Sonata may be better if you have trouble falling asleep while Ambien may be more effective for staying asleep:

"While zaleplon may be best indicated for the delayed onset of sleep, zolpidem [Ambien] and zopiclone [Sonata] may be better indicated for maintaining a complete night's sleep. Only the patient's symptoms and response to treatment will dictate the best course of treatment.

Ambien and Sonata are both effective medications for the treatment of short-term insomnia. Speak with your doctor regarding which may be the most appropriate choice for you.