CNS Pharmacology USMLE Step 1 Practice Question
A 45-year-old man presents with a 2-year history of nightly zolpidem 10 mg use for chronic insomnia. He reports increasing daytime somnolence, two episodes of complex sleep behavior (preparing food while asleep), and difficulty recalling conversations from the previous day. His wife notes he seems less alert in the mornings. Vital signs are normal. Physical examination is unremarkable. Mini-Cog score is 26/30. Polysomnography shows normal sleep architecture with appropriate REM and non-REM distribution. Laboratory studies including TSH, vitamin B12, and metabolic panel are normal. He denies current mood symptoms. Which of the following represents the most appropriate next step in management?
Answer choices
- ASwitch to triazolam 0.25 mg nightly for more predictable pharmacokinetics
- BSwitch to ramelteon 8 mg nightly and taper zolpidem gradually over 2-4 weeksCorrect answer
- CContinue zolpidem but reduce dose to 5 mg and add doxepin 10 mg for improved efficacy
- DSwitch to amitriptyline 25 mg nightly as a tricyclic antidepressant with sleep-promoting properties
- EDiscontinue zolpidem abruptly and initiate cognitive behavioral therapy for insomnia (CBT-I)
- FSwitch to phenobarbital 30 mg nightly for longer-acting GABA-A agonism with reduced tolerance
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