What medications can be offered for insomnia (poor sleep)?

From the Guidelines

For poor sleep, I strongly recommend starting with eszopiclone (2-3mg) or zolpidem (10mg) as they have been suggested by clinicians for the treatment of sleep onset and sleep maintenance insomnia in adults, as stated in the American Academy of Sleep Medicine clinical practice guideline 1. When considering treatment options for poor sleep, it's essential to evaluate the effectiveness and safety of various medications.

• The American Academy of Sleep Medicine suggests using suvorexant (10,15/20, and 20 mg doses) for sleep maintenance insomnia, eszopiclone (2 mg and 3 mg doses) for sleep onset and sleep maintenance insomnia, and zolpidem (10 mg dose) for sleep onset and sleep maintenance insomnia 1.
• Other options include zaleplon (10 mg dose) for sleep onset insomnia, triazolam (0.25 mg dose) for sleep onset insomnia, and temazepam (15 mg dose) for sleep onset and sleep maintenance insomnia 1.
• Melatonin agonists like ramelteon (8 mg dose) can be used for sleep onset insomnia, while heterocyclics like doxepin (3 mg and 6 mg doses) can be used for sleep maintenance insomnia 1.
• It's crucial to note that some medications, such as trazodone, tiagabine, diphenhydramine, melatonin, L-tryptophan, and valerian, are not recommended for the treatment of sleep onset or sleep maintenance insomnia due to limited evidence or potential side effects 1. Before initiating any medication, it's essential to practice good sleep hygiene, including maintaining a regular sleep schedule, avoiding screens before bed, limiting caffeine and alcohol, and creating a comfortable sleep environment.
• Medications should be started at the lowest effective dose and used intermittently rather than nightly to prevent tolerance and dependence.
• If insomnia persists beyond 2-4 weeks despite medication, it's essential to consult a healthcare provider to evaluate for underlying conditions like sleep apnea, restless leg syndrome, or psychiatric disorders.

From the FDA Drug Label

Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo. Ramelteon reduced sleep latency at each time point when compared to placebo One poor sleep medication that can be offered is ramelteon (PO), as it has been shown to reduce latency to persistent sleep and sleep latency in subjects with chronic insomnia 2.

• The recommended dose is 8 mg per night, as the 16 mg dose was found to confer no additional benefit for sleep initiation and was associated with higher incidences of fatigue, headache, and next-day somnolence 2.
• Ramelteon has been evaluated for its efficacy in both younger adults and older adults with chronic insomnia, and has been found to be effective in reducing sleep latency in both populations 2, 2.

From the Research

Poor Sleep Medication Options

There are several medication options available to treat poor sleep, including:

• Non-benzodiazepine sedative-hypnotic agents, such as zolpidem, zaleplon, and eszopiclone 3, 4, 5
• Melatonin receptor agonists, such as ramelteon 3, 6
• Benzodiazepines, although their use is generally not recommended due to the risk of dependence and other adverse effects 4, 5, 6
• Sedating antihistamines, such as diphenhydramine, although their use is not recommended due to the risk of adverse effects 3
• Orexin receptor antagonists, such as suvorexant, which can improve sleep maintenance 6

Considerations for Medication Use

When considering medication for poor sleep, it is essential to:

• Evaluate patient-specific criteria, such as age, medical history, and other drug use 3
• Use the minimum effective dose and for the minimum duration of time 3
• Monitor for adverse effects, such as cognitive impairment, dependence, and complex sleep-related behaviors 4, 7
• Consider non-pharmacologic options, such as cognitive behavioral therapy, sleep hygiene education, and relaxation therapy 3, 6

Specific Medication Options

Some specific medication options for poor sleep include:

• Zolpidem, which can be effective for sleep onset and maintenance, but has a risk of adverse effects, such as complex sleep-related behaviors and dependence 7
• Ramelteon, which can be effective for sleep onset insomnia, but has a risk of adverse effects, such as dizziness and nausea 3, 6
• Eszopiclone, which can be effective for sleep onset and maintenance, but has a risk of adverse effects, such as cognitive impairment and dependence 4, 6