What are the adjuncts to Ambien (zolpidem) for insomnia?

From the Guidelines

Ambien (zolpidem) should be used as a short-term treatment for insomnia, in conjunction with cognitive behavioral therapy for insomnia (CBT-I) and consistent sleep hygiene practices, to minimize risks of tolerance and dependence. When considering adjuncts to Ambien for insomnia, it's essential to prioritize evidence-based treatments that address the underlying causes of insomnia. According to the American College of Physicians guideline 1, CBT-I should be considered the first-line treatment for adults with chronic insomnia disorder, due to its effectiveness in improving global outcomes, sleep onset latency, and wake after sleep onset.

The American Academy of Sleep Medicine clinical practice guideline 1 suggests that clinicians use eszopiclone, zaleplon, or zolpidem as treatments for sleep onset and sleep maintenance insomnia in adults. However, the use of Ambien (zolpidem) should be limited to short-term treatment, and clinicians should use a shared decision-making approach to decide whether to add pharmacological therapy 1.

In terms of adjunctive treatments, relaxation techniques such as progressive muscle relaxation, deep breathing exercises, or meditation can enhance the effectiveness of Ambien. However, the use of melatonin, diphenhydramine, and other over-the-counter preparations is not recommended as a treatment for sleep onset or sleep maintenance insomnia 1.

Overall, a multimodal approach that combines Ambien with CBT-I, sleep hygiene practices, and relaxation techniques can help establish sustainable sleep patterns and reduce the risks associated with long-term use of sedative-hypnotic medications. This approach prioritizes the patient's morbidity, mortality, and quality of life, and is supported by the most recent and highest-quality evidence 1.

Key considerations for clinicians include:

• Using Ambien as a short-term treatment for insomnia
• Combining Ambien with CBT-I and sleep hygiene practices
• Avoiding the use of melatonin, diphenhydramine, and other over-the-counter preparations as treatments for insomnia
• Using a shared decision-making approach to decide whether to add pharmacological therapy
• Prioritizing the patient's morbidity, mortality, and quality of life when selecting treatments for insomnia.

From the FDA Drug Label

1. Indications and Usage Section 1 INDICATIONS AND USAGE Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. The FDA drug label does not answer the question about Ambien adjuncts to insomnia.

From the Research

Ambien Adjuncts to Insomnia

• There is no direct evidence in the provided studies to support the use of Ambien adjuncts to insomnia.
• However, the studies suggest that non-pharmacological approaches, such as cognitive-behavioral therapy for insomnia (CBT-i), are effective in managing insomnia 2, 3, 4, 5, 6.
• CBT-i is recommended as a first-line treatment for chronic insomnia, with benefits including no side effects, fewer episodes of relapse, and long-term improvements in sleep quality 2, 5, 6.
• The use of Ambien or other sleep medications may be associated with adverse effects, and non-pharmacological approaches are generally preferred 3, 4, 6.
• Studies have shown that CBT-i can be effective in patients with mental disorders and comorbid insomnia, including depression, post-traumatic stress disorder (PTSD), and alcohol dependency 6.

Non-Pharmacological Approaches

• CBT-i is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep, and is delivered over the course of six to eight sessions 5.
• Core components of CBT-i include sleep restriction therapy, stimulus control therapy, sleep hygiene, and cognitive therapy 5.
• Other non-pharmacological approaches, such as exercise and relaxation techniques, may also be effective in managing insomnia 3, 4.
• Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine, may also be considered 3, 4.

Treatment Recommendations

• Primary care physicians may use pharmacologic and non-pharmacologic approaches to manage insomnia, with non-pharmacologic approaches generally considered first-line treatment 3.
• CBT-i should be considered as a first-line treatment for patients with mental disorders and comorbid insomnia, given the many side effects of medication 6.