From the Guidelines
When Ambien (zolpidem) and Belsomra (suvorexant) are no longer effective for treating insomnia, the most recommended next step is to consider Cognitive Behavioral Therapy for Insomnia (CBT-I) as a first-line treatment, as it has been shown to improve global outcomes and sleep quality in adults with chronic insomnia disorder 1.
Treatment Options
Other treatment options to consider include:
- Trying other prescription medications like Lunesta (eszopiclone) at 1-3mg, which has been shown to improve short-term global and sleep outcomes compared with placebo 1
- Dayvigo (lemborexant) at 5-10mg, which works on orexin receptors differently than Belsomra
- Trazodone at 25-100mg before bedtime, although evidence for its effectiveness is limited
Non-Medication Approaches
In addition to medication, it is essential to improve sleep hygiene by:
- Maintaining consistent sleep-wake times
- Avoiding screens before bed
- Limiting caffeine and alcohol
- Creating a cool, dark sleeping environment
Further Evaluation
If these approaches fail, a comprehensive sleep study may be necessary to identify underlying conditions like sleep apnea or restless leg syndrome. A sleep specialist can help determine the most appropriate treatment based on your specific insomnia pattern and medical history.
Key Considerations
It is crucial to weigh the benefits and harms of pharmacologic treatments, as they may cause cognitive and behavioral changes, including driving impairment, and other adverse effects 1. CBT-I, on the other hand, has been shown to have mild or no harms associated with it 1.
From the Research
Next Steps for Treating Insomnia
After Ambien (zolpidem) and Belsomra (suvorexant) have proven ineffective, the next steps for treating insomnia may include:
- Considering alternative pharmacological treatments, such as ramelteon, a selective melatonin receptor agonist, which has been shown to improve sleep quality and reduce sleep latency 2, 3
- Implementing behavioral interventions, such as cognitive behavioral therapy for insomnia (CBT-I), which can help address underlying sleep habits and patterns
- Improving sleep hygiene practices, such as establishing a consistent sleep schedule, creating a relaxing sleep environment, and avoiding stimulating activities before bedtime
- Managing psychological stressors, such as anxiety and depression, which can contribute to insomnia
Alternative Treatment Options
Some alternative treatment options for insomnia include:
- Ramelteon, which has been shown to be effective in reducing sleep latency and improving sleep quality, with a low risk of adverse events 2, 3
- Other non-benzodiazepine hypnotics, such as eszopiclone and zaleplon, which may be considered as alternative treatment options
- Melatonin receptor agonists, such as tasimelteon, which may be effective in treating insomnia, particularly in patients with circadian rhythm disorders
Important Considerations
When considering alternative treatment options, it is essential to:
- Consult with a healthcare professional to determine the best course of treatment
- Carefully evaluate the potential benefits and risks of each treatment option
- Monitor treatment response and adjust the treatment plan as needed
- Consider the potential for rebound insomnia and other adverse effects when discontinuing or switching treatments, as seen with zolpidem 4, 5