What are the medications for insomnia (sleep disorder)?

From the Guidelines

Medications for insomnia should be used judiciously, with a preference for cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, and pharmacological therapy should only be considered when CBT-I is unsuccessful, with eszopiclone, zolpidem, and suvorexant being potential options. When considering pharmacological therapy, the following medications have been suggested as treatment options for insomnia:

• Orexin receptor agonists: Suvorexant, which can be used for sleep maintenance insomnia at doses of 10,15/20, and 20 mg 1
• BZD receptor agonists: Eszopiclone, which can be used for sleep onset and sleep maintenance insomnia at doses of 2 mg and 3 mg 1
• Zaleplon, which can be used for sleep onset insomnia at a dose of 10 mg 1
• Zolpidem, which can be used for sleep onset and sleep maintenance insomnia at a dose of 10 mg 1
• Melatonin agonists: Ramelteon, which can be used for sleep onset insomnia at a dose of 8 mg 1
• Heterocyclics: Doxepin, which can be used for sleep maintenance insomnia at doses of 3 mg and 6 mg 1 It is essential to note that these medications should be used short-term (2-4 weeks) to avoid dependence and should be combined with good sleep hygiene practices, such as maintaining a regular sleep schedule, avoiding screens before bed, and creating a comfortable sleep environment 1. Some key points to consider when prescribing medications for insomnia include:
• The potential for dependence and side effects associated with benzodiazepines and non-benzodiazepine "Z-drugs" 1
• The importance of using the lowest effective dose and monitoring for adverse effects 1
• The need for a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications 1

From the FDA Drug Label

Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.

Medications for insomnia include:

• Zolpidem (2): indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation.
• Ramelteon (3): indicated for the treatment of insomnia characterized by difficulty with sleep onset. Key points to consider when prescribing these medications include:
• Efficacy: Zolpidem has been shown to decrease sleep latency for up to 35 days in controlled clinical studies (2).
• Duration of treatment: The clinical trials performed in support of efficacy for Zolpidem were 4 to 5 weeks in duration (2), while Ramelteon was studied for up to six months (3).

From the Research

Medications for Insomnia

• Insomnia is a common sleep disorder that can be treated with a multi-disciplinary approach, including behavioral interventions, sleep hygiene, psychological stressors management, hypnotic treatment, and pharmacological therapy 4.
• Non-benzodiazepine hypnotics such as zolpidem, eszopiclone, and zaleplon are commonly used as adjunctive treatment for insomnia 4, 5.
• Zolpidem is a widely used medication for insomnia, but it has a range of adverse effects, including an increased risk of falls, hip fractures, and complex behaviors such as sleepwalking and hallucinations 4.
• The choice of hypnotic agent in the elderly is symptom-based, with options including ramelteon, short-acting Z-drugs, suvorexant, and low-dose doxepin 6.
• Pharmacotherapy for insomnia should be individualized, taking into account the patient's medical history, age, and other factors, and should be used in conjunction with cognitive behavioral therapy for insomnia (CBT-I) 7.
• A meta-analysis of polysomnographic randomized controlled trials found that benzodiazepine receptor agonists and classical benzodiazepines had higher effect sizes for objective outcomes compared to antidepressants and other medication classes 8.

Types of Medications for Insomnia

• Non-benzodiazepine hypnotics:
  • Zolpidem
  • Eszopiclone
  • Zaleplon
• Benzodiazepines:
  • Triazolam
  • Temazepam
• Melatonin receptor agonists:
  • Ramelteon
• Orexin receptor antagonists:
  • Suvorexant
• Antidepressants:
  • Low-dose doxepin
• Histamine receptor inverse agonists:
  • APD-125, eplivanserin, and LY2624803 (although these have been withdrawn from development) 5, 6, 7

Considerations for Medication Use

• Age: elderly patients may require adjusted doses due to slower drug metabolism 4, 6.
• Medical history: patients with a history of substance abuse or psychiatric illness may be at greater risk for dependence and abuse 5.
• Side effects: medications for insomnia can have a range of side effects, including residual daytime sleepiness, risk of falls, and complex behaviors 4, 5.
• Pregnancy and lactation: zolpidem is classified as a category C drug, with potential risks to the fetus and infant 4.