rescribe a lower initial dose of the opioid and titrate based upon clinical response. advise both patients and caregivers about the risks of respiratory depression and sedation when temazepam is used with opioids. advise patients not to drive or operate heavy machinery until the effects of concomitant use with the opioid have been determined ( see precautions, drug interactions ). abuse, misuse, and addiction the use of benzodiazepines, including temazepam, exposes users to the risks of abuse, misuse, and addiction, which can lead to overdose or death. abuse and misuse of benzodiazepines often (but not always) involve the use of doses greater than the maximum recommended dosage and commonly involve concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes, including respiratory depression, overdose, or death ( see drug abuse and dependence, abuse ). before prescribing temazepam and throughout treatment, assess each patient’s risk for abuse, misuse, and addiction (e.g., using a standardized screening tool). use of temazepam, particularly in patients at elevated risk, necessitates counseling about the risks and proper use of temazepam along with monitoring for signs and symptoms of abuse, misuse, and addiction. prescribe the lowest effective dosage; avoid or minimize concomitant use of cns depressants and other substances associated with abuse, misuse, and addiction (e.g., opioid analgesics, stimulants); and advise patients on the proper disposal of unused drug. if a substance use disorder is suspected, evaluate the patient and institute (or refer them for) early treatment, as appropriate. dependence and withdrawal reactions to reduce the risk of withdrawal reactions, use a gradual taper to discontinue temazepam or reduce the dosage (a patient-specific plan should be used to taper the dose) ( see dosage and administration, discontinuation or dosage reduction of temazepam ). patients at an increased risk of withdrawal adverse reactions after benzodiazepine discontinuation or rapid dosage reduction include those who take higher dosages, and those who have had longer durations of use. acute withdrawal reactions the continued use of benzodiazepines, including temazepam, may lead to clinically significant physical dependence. abrupt discontinuation or rapid dosage reduction of temazepam after continued use, or administration of flumazenil (a benzodiazepine antagonist) may precipitate acute withdrawal reactions, which can be life-threatening (e.g., seizures) ( see drug abuse and dependence, dependence ) . protracted withdrawal syndrome in some cases, benzodiazepine users have developed a protracted withdrawal syndrome with withdrawal symptoms lasting weeks to more than 12 months ( see drug abuse and dependence, dependence ). sleep disturbance may be the presenting manifestation of an underlying physical and/or psychiatric disorder. consequently, a decision to initiate symptomatic treatment of insomnia should only be made after the patient has been carefully evaluated. the failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. worsening of insomnia may be the consequence of an unrecognized psychiatric or physical disorder as may the emergence of new abnormalities of thinking or behavior. such abnormalities have also been reported to occur in association with the use of drugs with central nervous system depressant activity, including those of the benzodiazepine class. because some of the worrisome adverse effects of benzodiazepines, including temazepam, appear to be dose related ( see precautions and dosage and administration ), it is important to use the lowest possible effective dose. elderly patients are especially at risk. some of these changes may be characterized by decreased inhibition, e.g., aggressiveness and extroversion that seem out of character, similar to that seen with alcohol. other kinds of behavioral changes can also occur, for example, bizarre behavior, agitation, hallucinations, and depersonalization. complex behaviors such as “sleep-driving” (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported. these events can occur in sedative-hypnotic-naïve as well as in sedative-hypnotic-experienced persons. although behaviors such as “sleep-driving” may occur with temazepam alone at therapeutic doses, the use of alcohol and other cns depressants with temazepam appears to increase the risk of such behaviors, as does the use of temazepam at doses exceeding the maximum recommended dose. due to the risk to the patient and the community, discontinuation of temazepam should be strongly considered for patients who report a “sleep-driving” episode. other complex behaviors (e.g., preparing and eating food, making phone calls, or having sex) have been reported in patients who are not fully awake after taking a sedative-hypnotic. as with “sleep-driving”, patients usually do not remember these events. amnesia and other neuro-psychiatric symptoms may occur unpredictably. in primarily depressed patients, worsening of depression, including suicidal thinking has been reported in association with the use of sedative/hypnotics. it can rarely be determined with certainty whether a particular instance of the abnormal behaviors listed above is drug induced, spontaneous in origin, or a result of an underlying psychiatric or physical disorder. nonetheless, the emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation. because temazepam can cause drowsiness and a decreased level of consciousness, patients, particularly the elderly, are at higher risk of falls. severe anaphylactic and anaphylactoid reactions rare cases of angioedema involving the tongue, glottis or larynx have been reported in patients after taking the first or subsequent doses of sedative-hypnotics, including temazepam. some patients have had additional symptoms such as dyspnea, throat closing, or nausea and vomiting that suggest anaphylaxis. some patients have required medical therapy in the emergency department. if angioedema involves the tongue, glottis or larynx, airway obstruction may occur and be fatal. patients who develop angioedema after treatment with temazepam should not be rechallenged with the drug.

pregnant patient received temazepam and diphenhydramine. a cause and effect relationship has not yet been determined ( see contraindications ).

burning eyes amnesia, hallucinations, horizontal nystagmus, and paradoxical reactions including restlessness, overstimulation and agitation were rare (less than 0.5%). to report suspected adverse events, contact teva at 1-888-838-2872 or fda at 1-800-fda-1088 or http://www.fda.gov/ for voluntary reporting of adverse reactions.

time curve over the 15 to 30 mg dose range. temazepam was completely metabolized through conjugation prior to excretion; 80% to 90% of the dose appeared in the urine. the major metabolite was the o-conjugate of temazepam (90%); the o-conjugate of n-desmethyl temazepam was a minor metabolite (7%). bioavailability, induction, and plasma levels following ingestion of a 30 mg temazepam capsule, measurable plasma concentrations were achieved 10 to 20 minutes after dosing with peak plasma levels ranging from 666 to 982 ng/ml (mean 865 ng/ml) occurring approximately 1.2 to 1.6 hours (mean 1.5 hours) after dosing. in a 7 day study, in which subjects were given a 30 mg temazepam capsule 1 hour before retiring, steady-state (as measured by the attainment of maximal trough concentrations) was achieved by the third dose. mean plasma levels of temazepam (for days 2 to 7) were 260±210 ng/ml at 9 hours and 75±80 ng/ml at 24 hours after dosing. a slight trend toward declining 24 hour plasma levels was seen after day 4 in the study, however, the 24 hour plasma levels were quite variable. at a dose of 30 mg once-a-day for 8 weeks, no evidence of enzyme induction was found in man. elimination rate of benzodiazepine hypnotics and profile of common untoward effects the type and duration of hypnotic effects and the profile of unwanted effects during administration of benzodiazepine hypnotics may be influenced by the biologic half-life of the administered drug and for some hypnotics, the half-life of any active metabolites formed. benzodiazepine hypnotics have a spectrum of half-lives from short (less than 4 hours) to long (greater than 20 hours). when half-lives are long, drug (and for some drugs their active metabolites) may accumulate during periods of nightly administration and be associated with impairments of cognitive and/or motor performance during waking hours; the possibility of interaction with other psychoactive drugs or alcohol will be enhanced. in contrast, if half-lives are shorter, drug (and, where appropriate, its active metabolites) will be cleared before the next dose is ingested, and carry-over effects related to excessive sedation or cns depression should be minimal or absent. however, during nightly use for an extended period, pharmacodynamic tolerance or adaptation to some effects of benzodiazepine hypnotics may develop. if the drug has a short elimination half-life, it is possible that a relative deficiency of the drug, or, if appropriate, its active metabolites (i.e., in relationship to the receptor site) may occur at some point in the interval between each night’s use. this sequence of events may account for 2 clinical findings reported to occur after several weeks of nightly use of rapidly eliminated benzodiazepine hypnotics, namely, increased wakefulness during the last third of the night, and the appearance of increased signs of daytime anxiety. controlled trials supporting efficacy temazepam improved sleep parameters in clinical studies. residual medication effects (“hangover”) were essentially absent. early morning awakening, a particular problem in the geriatric patient, was significantly reduced. patients with chronic insomnia were evaluated in 2 week, placebo controlled sleep laboratory studies with temazepam at doses of 7.5 mg, 15 mg, and 30 mg, given 30 minutes prior to bedtime. there was a linear dose-response improvement in total sleep time and sleep latency, with significant drug-placebo differences at 2 weeks occurring only for total sleep time at the 2 higher doses, and for sleep latency only at the highest dose. in these sleep laboratory studies, rem sleep was essentially unchanged and slow wave sleep was decreased. no measurable effects on daytime alertness or performance occurred following temazepam treatment or during the withdrawal period, even though a transient sleep disturbance in some sleep parameters was observed following withdrawal of the higher doses. there was no evidence of tolerance development in the sleep laboratory parameters when patients were given temazepam nightly for at least 2 weeks. in addition, normal subjects with transient insomnia associated with first night adaptation to the sleep laboratory were evaluated in 24 hour, placebo controlled sleep laboratory studies with temazepam at doses of 7.5 mg, 15 mg, and 30 mg, given 30 minutes prior to bedtime. there was a linear dose-response improvement in total sleep time, sleep latency and number of awakenings, with significant drug-placebo differences occurring for sleep latency at all doses, for total sleep time at the 2 higher doses and for number of awakenings only at the 30 mg dose.

to 30 mg dose range. temazepam was completely metabolized through conjugation prior to excretion; 80% to 90% of the dose appeared in the urine. the major metabolite was the o-conjugate of temazepam (90%); the o-conjugate of n-desmethyl temazepam was a minor metabolite (7%).